Women from around the world flock to David Matlock's marble waiting room carrying purses stuffed with porn. The magazines are revealed only in the privacy of his office, where doctor and patient debate the finer points of each glossy photo.
The enterprising gynecologist sees countless images of naked women, but none are more popular than Playboy's fresh-faced playmates. They represent, he says with a knowing smile, the perceived ideal.
"Some women will say, 'Hey, you take this picture and hang it up in the operating room and refer back to it when you're sculpturing me,'" he said in an interview in his clinic overlooking hazy Los Angeles. "I say, 'Okay, all right, fine.'"
Dr. Matlock is a colourful pioneer in a controversial - and growing - frontier of plastic surgery: nipping and tucking vaginas. Patients from the United States and more than 30 other countries pay thousands of dollars for his "designer vagina," a purely esthetic procedure that includes shortening or plumping up the labia, or vaginal lips. He attracts even more women for an operation he claims improves sex by tightening, or "rejuvenating," the vagina.
"There's a need for this," he said. "Women are driving this. I didn't create this market, the market was there."
While doctors have long known how to enhance women's genitals, demand for vaginal surgery has mushroomed in recent years because physicians - led by Dr. Matlock - market it as enhancing sexual satisfaction.
Doctors working in the field, including those in Canada, report higher caseloads and longer waiting lists. And the American Society of Plastic Surgeons says the increase is so great that it expects to soon start tracking volumes.
The trend has even reached girls as young as 15. In the past 18 months, the number of teens - and in one case an adolescent and her mother - who come to Dr. Matlock for designer vaginas has doubled.
"They're mature. Breasts, body, everything. I mean the clothing that they're wearing, the whole thing. These are not little girls. They're mature young ladies."
Plastic surgery's spread to women's nether regions alarms those who see it as a manifestation of society's air-brushed standards of the female form that exploits women's deep-seated insecurities.
"I think it's appalling and frightening and one more way in which perfectly normal, beautiful women are terrorized by the possibility of being less than a perfect 10," said Joy Davidson, a certified sex therapist and author in Seattle.
Michael Atkinson, a sociology professor at McMaster University in Hamilton, says the increasing popularity of cosmetic vaginal reconstruction is partly the outcome of the West's obsession with plastic surgery.
"This is essentially a cultural problem that we fix medically," said Prof. Atkinson, who studies cosmetic surgery. "We have this notion the body's a problem to be worked and if you slightly deviate from a supposed norm you should do something about it, which is really a market logic. That's how we make a lot of money in our culture, to plant these cultural ideals in people's heads and then try to enforce them."
However, women who have had their genitals surgically enhanced say it has transformed their lives. While some patients have genuine health problems, such as incontinence, many also ask their doctors to perform additional procedures while they are on the operating table. Others are solely driven by cosmetic or sexual reasons.
For the past 14 years, Julie Gause was troubled by the after-effects of an "extremely awful episiotomy," which is an incision to facilitate childbirth, that she had while delivering her son. But "the No. 1" reason she sought the surgery was to "enhance" her sex life.
"It's definitely going to be worth it for the rest of my life," the bubbly, tanned, 35-year-old Los Angeles resident said in an interview. "It takes you back to before children, for sure. It's an amazing difference. It's unbelievable."
In June, she paid Dr. Matlock $16,000 (U.S.) for what she laughingly called "the full monty": reconstruction of the after-effects of the episiotomy, reduction of her labia and tightening of her vaginal muscles.
Not all procedures are even surgical. On the recommendation of a friend, Katia Neves came to Dr. Matlock for the doctor's so-called G-shot, an $1,800 collagen-based injection in her G-spot that he says amplifies orgasms and lasts for about four months.
"It's a pretty expensive procedure for a short period of time," said the 36-year-old cosmetologist, who was born in Brazil and now lives in L.A. "It does increase your pleasure. It makes a difference, even if you don't have problems you can feel the difference."
Calgarian Sally Marshall turned to cosmetic surgery to fix something she first noticed at the age of 5: Her inner labia protruded beyond the outer lips, which made riding a bike and wearing a swimsuit or tight jeans an excruciating experience. She was also self-conscious about changing at the gym or having sex with a new partner.
Last year, Bruce Allan, a local obstetrician-gynecologist, trimmed her labia and tightened her vaginal walls for $3,700 (the price has since increased). The difference, she said, is "like night and day."
"Oh my heavens, I'm and sex has never been better!" she said. "Let me tell you, it does miracles for your husband, too. He loves it." The question of why women seek plastic surgery for an area of their bodies that few people - including themselves - ever really see is hotly debated. Critics note that men benefit when their partners undergo vaginal tightening and say they, along with society at large, intentionally or otherwise steer women's interest in genital enhancement.
"Does anybody wake up in the morning and say, 'I just really, really, really need to have my genitals reshaped because I just really want to do that because it's going to feel better'? " Prof. Atkinson asked.
Pornography's drift into the mainstream and a growing candour about sexuality often lead to the thorny subject of anatomical comparisons, says Leroy Young, chairman of the American Society of Plastic Surgeons' emerging trends task force.
"[Women]get a comment from their spouse or boyfriend or whoever that, 'Gee you don't look like whoever,' and a comment about a sensitive area like that, of course, is a huge emotional blow. So I think a lot of the women who pursue that are concerned about issues like, 'How am I going to be perceived?'"
While Dr. Matlock acknowledges vaginal tightening benefits men, he insists his patients come to him because they want change.
"They say, 'Look, I want to enjoy this. I want to have the best sexual experience possible. It's for me.' That's what they're doing. If a man was pushing a woman to come in, I'm not going to do it."
Still, a husband of a woman with stress incontinence in the mid-1990s played a large role in Dr. Matlock's inadvertent realization of the demand for vaginal reconstruction, which builds on decades-old surgical techniques. Some physicians have long quietly added an extra stitch "for the husband" while repairing new mothers' episiotomies.
After he treated her, the woman reported that her sex life had dramatically improved. Then her husband telephoned to thank Dr. Matlock profusely, and the couple sent flowers. And one of the woman's friends - who had vaginal-relaxation, not bladder, problems - contacted him seeking the same procedure.
"Then what happened is there was all these women coming by word of mouth," he said.
Soon Dr. Matlock, a trim, compact 45-year-old St. Louis, Mo., native with a throaty laugh, placed his first and only advertisement, which featured his then-girlfriend posing in a bikini.
The newspaper ad proclaimed the first sexual advance of the new millennium, saying: "You won't believe how good sex can be." The response was so overwhelming that he pulled it and now largely relies on personal recommendations and his website, which depicts images of flowers and attractive women.
In the process, Dr. Matlock, who is seen as a key figure in the field, turned vaginal reconstruction into a lucrative business empire. He says one of his divisions grosses $200,000 a month, but refused to provide additional financial information. Dr. Matlock, who also has an MBA, has trained doctors in 10 countries, including Canada, in his techniques and charges them a monthly fee of $2,500 for support and for the use of his trademarked names, including Laser Vaginal Rejuvenation Institute.
Depending on the surgical procedure, the women who come to his fourth-floor West Hollywood clinic across from a Jaguar car dealership pay between $3,800 and $17,000. Celebrities who want complete privacy fork over $38,000. Patients, who include housewives and porn stars, are largely in their 20s, 30s and 40s. Most are American, though about one-quarter are foreign. About half are mothers. All, he says, have normal sexual function.
Using lasers instead of scalpels for the one-hour outpatient surgeries, Dr. Matlock performs a weekly average of 10 procedures - which he demonstrates with his Montblanc pen and a transparent plastic model of a vagina along with graphic before-and-after pictures of his patients - and claims a six-month waiting list.
He creates designer vaginas by surgically enhancing the external genitalia, including labia majora and minora, vaginal opening and perineum, which, his website says, creates a "youthful and aesthetically appealing vulva." Trimming elongated or unequal labia is most common; some women get fat transplants to plump up their outer labia. (Some doctors also restore hymens for women, often from the Middle East, who want to appear to be virgins when they get married.) To tighten a woman's vagina, which Dr. Matlock calls laser vaginal rejuvenation, he decreases the vaginal opening by drawing muscles and support tissue together with an absorbable stitch. He also builds up the perineum, which is between the vagina and anus.
"It makes a tremendous difference for sexual gratification for the women. That's what the procedure is all about," he said.
But gynecological experts say there is no proof that vaginal tightening improves sex and warn the procedure risks harmful side effects, including infection, hemorrhaging, loss of sensation, nerve injury, formation of scar tissue as well as becoming too tight. (Dr. Matlock says he has been reluctant to submit studies for publication in medical journals because he does not want to reveal his techniques.) "There are definite potential downsides to this," said Dr. Young, adding that any possible benefits of tightening are not permanent.
There is no textbook outlining the ways and means that doctors can beautify the vagina. So Dr. Matlock, as he likes to say, gets all of his ideas by listening to women.
If they repeatedly make the same request, the man who has been called the Picasso of vaginas will attempt to turn wish into reality. He is currently developing what he calls a "lip tuck," a facelift of sorts that would shrink sagging skin around the vulva and create a more "youthful appearance."
He hones new techniques on animal parts - chicken thighs, turkey legs and pig's ears - until he is ready to work on women.
"It's basically all about art. I'm an artist."