Eyes. Lips. Nose. Chin. Cheeks. Neck. Breasts. Abdomen. Hips. The inventory of imperfect body parts that bother women and lead them to undergo cosmetic plastic surgery was already extensive.
It has now reached bottom.
According to the American Society for Aesthetic Plastic Surgery, during the last few years, demand for cosmetic labiaplasty, a trimming of the female genitalia, has increased dramatically.
In 2005, this is how many labiaplasties Adrian Lo, a prominent Philadelphia plastic surgeon, performed: Zero.
Last year? Fifty.
"There has been a cultural shift," Lo said.
It began with a change in grooming habits. An estimated 80 percent of American women currently trim, shave, wax, or undergo laser treatments to remove some or all of their pubic hair. As a result, Lo said, women are scrutinizing - and finding fault with - parts of themselves that had always been camouflaged.
Though the Aesthetic Plastic Surgery society notes that the sum total of labiaplasties remains relatively small, with about 5,000 performed in 2013, that figure set a record and represented a 44 percent increase over the previous year.
It is normal in adult women for the inner lips to extend beyond the outer labia and for this tender skin to take on a darker hue around the edges, Lo said. After childbirth and with age, the labia may stretch further.
The surgery, which is relatively low-risk, usually costs between $3,000 and $6,000 and generally can be done under local anesthesia as an outpatient procedure.
To achieve aesthetic proportions, Lo said, he may suggest that the outer lips - or labia majora - be reduced, and, in some cases, the clitoral hood as well. The procedure poses no risk to the patient's sexual sensitivity because it does not involve the clitoris itself.
Most patients requesting labiaplasty are in their 30s and 40s and tell their doctors that the excess flesh is uncomfortable when they ride bicycles or have sex or that they are self-conscious about wearing revealing, tight-fitting clothes such as yoga pants and bathing suits.
"When I walked into the gym," said Sharon Sheridan, "I always felt that people were staring at my crotch."
Sheridan is a 54-year-old independent sales contractor who lives in Bucks County and supplies luxury-brand eyewear to optical stores. She said cultural trends had nothing to do with her desire for the surgery.
She had been embarrassed about her proportions long before she, or anyone she knew, had ever heard of a Brazilian, the wax job that removes all pubic hair. Feeling "mortified" by her appearance interfered with her sex life, she said.
"It was always a conversation I had before being intimate with someone," Sheridan said. "I would say, 'I have to warn you. I'm horrible.' "
Invariably, Sheridan said, her partner would respond: "What do you mean? You're normal!"
Which seems to reflect the views of a majority of men.
"Most don't care. Some actually prefer a little dangling," said Christine Hamori, an assistant professor of surgery at Boston Medical Center, who is now doing about 100 labiaplasties a year.
Consistent with national reports, Hamori said, she is seeing an alarming increase in teenage girls coming to her for surgery to achieve a prepubescent look.
"There is this misconception that your vaginal area should look like a child's, with no protrusions," Hamori said. "I have a lot of trouble convincing people that what they are asking for is not the norm."
Lo said a small number of his younger patients really have had disproportionately large labia, and after the surgery, they have felt greatly relieved.
"Obviously, there is a psychological component," he said. Without passing judgment, Lo said, he feels obligated to respect a woman's right to choose the way she wants to look and the potential benefits to her self-esteem, while honoring the physician's obligation to "do no harm."
"If a woman's labia are normal, I'll say, 'You are not a surgical candidate,' " Lo said.
Patients, however, do not always take no for an answer.
At times, when Lo has declined to do a face-lift or perform liposuction on someone he believes will not benefit from the surgery, the patient has simply found another doctor to do the job.
"I say no all the time," Lo said, "because I have to sleep at night."
Hamori's experience is similar.
"If you turn them away, they're often angry and unhappy," Hamori said. Her concern with labiaplasty when the patient is very young or asks for an extreme reduction is that the results will not only be disfiguring, but also physically harmful.
"Labia have a function as a protective barrier and to provide lubrication," she said. "Some women want a coin slot. It's distorted. And with young women, as they grow, they may develop a gaping of the posterior vagina."
A debate over the ethics of labiaplasty and other cosmetic gynecological operations that tighten the vagina or even reconstruct the hymen has made its way into several mainstream medical journals.
Critics have blamed profit-seeking doctors and indiscriminate media coverage for promoting the trend. Some say the procedure should be considered a form of genital mutilation, especially the most radical iteration being marketed as "The Barbie."
In the December issue of the American Journal of Obstetrics and Gynecology, Rebecca G. Rogers, a doctor in the department of obstetrics and gynecology at the University of New Mexico Health Sciences Center, wrote, "One wonders if the marketing of 'ideal' labial appearance purporting to improve the lives of women is just another form of further exploiting the social vulnerability of women."
Presenting the alternative view, Rachel N. Pauls, a doctor in the Division of Urogynecology and Reconstructive Pelvic Surgery at TriHealth Good Samaritan Hospital in Cincinnati, argued that doctors must be careful not to tread on their patients' autonomy. As long as there is a reasonable expectation that labiaplasty will help a woman feel more comfortable and self-confident, the surgery should be considered a form of healing.
After interviewing several surgeons, Sheridan said, she chose Lo to do the surgery in November.
"It's a hard thing to do," she said, but she had faith in Lo because of his experience doing reconstructive work on women after cancer surgery.
She had no doubts going into the operating room, she said, and has no regrets now that it's done.
"I was not comfortable in my own skin before," she said, "and I am now."