Received: 31 March 2022 | Revised: 28 September 2022 | Accepted: 19 October 2022

DOI: 10.1111/jocd.15484

REVIEW ARTICLE

Cosmetic gynecology—­An emerging field for the dermatologist

Anuradha Jindal MBBS, MD, FRGUHS | Venkataram Mysore MBBS, DVD, MD, DNB,
DipRCPath, FRCP, FISHRS | Jayashree Venkataram Mysore MBBS, FRCOG

Venkat Institute of Skin and plastic

surgery, Karnataka, Bangalore, India Abstract
Introduction: Cosmetic gynecology is an expanding field with a steep rise in aware-
Correspondence
Anuradha Jindal, Skin-­win clinic, GSJ ness and demand for procedures to enhance the aesthetic appearance of female
royale building, Santhekatte, Udupi,
genitalia.
Karnataka 576114, India.
Email: [email protected] Aim: This article aims to provide an overview of aesthetic gynecology for a practicing
dermatologist.
Methods: A study conducted in India showed a rising trend in the demand of aesthetic
vaginal procedures from 3.9% in 2012 to 28.97% in 2015.
Conclusion: Several aesthetic modalities such as peels, platelet rich plasma, and
energy-­based devices and surgical modalities have been in use, though serious evi-
dence for efficacy of many of these procedures is lacking.

KEYWORDS
aesthetic gynecology, carbon-­dioxide lasers, cosmetic gynecology, female rejuvenation,
O-­shots

1 | I NTRO D U C TI O N aesthetic implications, aesthetic treatments such as lasers are best

known and used by dermatologists and because dermatologists
With the growing fascination for the “perfect body” in this era, have a sense of aesthetics. This subject has not been adequately
guided by the overarching the influence of social media, the de- dealt with in dermatological journals and this article gives a brief
sire has extended to achieve “perfect genitalia.” This has led to overview of this topic.
the emergence of cosmetic gynecology as a growing subject in-
volving multiple disciplines gynecology, urogynecology, urology,
plastic surgeons, and dermatology. The scope of this field includes 2 | P S YC H O LO G I C A L I M PAC T
both concerns of aesthetic appearance of the external genitalia
and functional concerns to improve the sexual wellness or qual- There has been a dramatic increase in female genital cosmetic sur-
ity of life, caused by both dermatological problems such as aging gery (FGCS) by 39% from 2015 to 2016, which was greater than any
changes, pigmentary diseases, and gynecological conditions such other type of cosmetic surgery field.1 Among all the FGCS, maximum
as vaginal atrophy, laxity, and stress incontinence. Several aesthetic surge has been seen in labiaplasty or alteration in labia, being con-
modalities such as peels, platelet rich plasma, and energy-­based de- ducted even in teenagers younger than 14 years. Surgical procedures
vices and surgical modalities have been advocated, though serious may be supplemented with non-­invasive energy-­based procedures
evidence for efficacy of many of these procedures is lacking. The such as the use of lasers and radiofrequency for vaginal rejuvena-
role of dermatologist in this field will become increasingly import- tion. Being non-­invasive, easier to perform and due to lesser down-
ant due to several reasons; several dermatological conditions have time energy-­based devices have gained lot of popularity among the

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2022 The Authors. Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.

J Cosmet Dermatol. 2023;22:111–118.  wileyonlinelibrary.com/journal/jocd | 111

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112 JINDAL et al.

physicians and patients. A study conducted in India showed a rising 3 | A N ATO M Y O F E X TE R N A L G E N ITA LI A
trend in the demand of aesthetic vaginal procedures from 3.9% in
2012 to 28.97% in 2015. 2 A brief knowledge of anatomy of external genitalia is important
The surge in demand of FGCS can be attributed to multiple fac- while planning any cosmetic procedure. The female external geni-
tors, crucial one being increased exposure social media, idealization talia (the vulva), from anterior to posterior, is formed by the mons
of the perfect body and also perfect genitalia and to an extent in- pubis, labia majora, labia minora, vulvar vestibule, external urethral
ternet pornography. The concept of “designer vulva” or “barbie doll meatus, hymen, ostia of the accessory glands (Bartholin's, Skene's,
vulva” has led to shift in perception of “normal” vagina. The size, and vesitubular glands), and the perineum5 (Figure 1). The mons
shape, texture, and color of the vulva varies with the age, ethnicity, pubis lies anterior to pubic bone and consists of fatty tissue. The
hormonal status, and sexual and personal history. But the informa- labia major are two skin folds extending posteriorly from the mons
tion on internet, pornography, and media has started dictating stan- pubis till posterior fourchette. The labia minora are cutaneous folds
dard norms for “normal appearance” of the genitalia leaving a large located medial to labia majora and consists of much less subcuta-
chunk of women feeling anxious, insecure with lower self-­esteem. neous tissue than labia majora. The outer surface of labia majora is
Other important factors being trend of hairless pubic area with use covered with hair follicles whereas labia minora is completely devoid
of lasers or Brazilian wax leading to increase in self-­examination of of hair follicles. The anterior surface of the labia minora consists of a
external genital; unrealistic expectation by the male partner which clitoral hood and frenulum. The external uretheral opening is located
are usually derived from the exotic movies, magazines, decreased 2.5 cm behind the glans clitoris and anterior to vaginal opening. The
society inhibitions, cultural change with acceptance of exhibitionist clitoris is the sexual organ present in females analogous to penis in
tendencies of human body, and increasing materialism. males. The rounded portion of clitoris is located near the anterior
Studies have shown that majority of women who get the sur- junction of the labia minora, above the openings of the urethera and
gery done are suffering from narcissistic personality or histrionic vagina. The clitoral body is around 2.5 cm long and is attached to the
personality (defined in terms of attention seeking behavior and ex- pubic bone with the help of a suspensory ligament.5,6
treme emotionality) with many of them suffering from body dysmor-
phic disorder (BDD). Therefore, complete psychological evaluation
before performing FGCS and psychological counseling if needed 4 | CO N C E P T S O F B E AU T Y O F FE M A LE
should be provided before proceeding toward the procedure. 3
G E N ITA LI A
A prospective, control group study conducted in 120 subjects
included patients undergoing interventions such as labiaplasty, cli- Concept of beauty and aesthetics of external genitalia is, like
toral hood reduction, and/or aesthetic vaginal tightening, defined as other part of the body, also inspired by nature and symmetry.
perineoplasty + “vaginoplasty” (aka “vaginal rejuvenation.”) showed Historically, external female genitalia have been likened to a
improvement in body image, genital self-­image, sexual satisfaction, flower. Cltoria-­ternatea is a flower aka aprajitha in India which is
and body esteem postoperatively.4 reserved as a holy flower for daily puja rituals. The holy flower is

F I G U R E 1 Diagram of external genitalia with important features highlighted in the box

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JINDAL et al. 113

said to represent the shape of female genitalia. (Figure 2). In an- Box 1 Classification of conditions affecting external genitalia
cient India, female genital has also been depicted with symbols of (a) Dermatological conditions with aesthetic implications
fish, double oval, and triangle. An approach to define the beauty (b) Gynecological problems leading to aesthetic problems
and symmetry of female genitalia is using concept of circles and (c) Gynecological conditions leading to functional issues
triangles. This concept is borrowed from the widely used tradi- Table 1 shows a list of different conditions in these categories.
tional symbols both in religion and architecture for centuries as
Vesica Piscis and Reuleaux triangle. Vesica Piscis, which means
“fish bladder” is a symbol made from the intersection of two cir- 4.1 | Gynecological conditions leading to
cles of the same radius and where the center of each circle lies functional issues
on the circumference of the other. Reuleaux triangle is a shape
formed from the intersection of the circles. Vaginal laxity is a sensation of looseness of the vagina which may
When applied to the female external genitalia, this translates in develop after pregnancy and vaginal delivery, although it may also
to three concentric rings with a top spot (Mons pubis) and a central be affected by prior pelvic surgery, menopause, and aging. Vaginal
spot in clitoris. laxity syndrome is under reported and many a times unrecognized by
the individual.8 Vaginal laxity can result in decreased genito-­pelvic
1. Outermost ring comprising the groin area on both sides sensation during sexual intercourse and can cause decreased sexual
2. The middle ring of labia majora pleasure for both men and women.9
3. The inner most ring of labia minora-­with the central clitoris. Pelvic organ prolapse (POP) is a disorder in which one or more of
the pelvic organs descends from the normal position. Vaginal laxity
Hichem Bensmail has expanded on these concepts and described is differentiated from POP in that prolapse involves the descent of
four triangles within the circles: one or more organs whereas laxity focuses on looseness of the va-
(A) a top triangle (triangle of pleasure where clitoris and G spot are gina, commonly at the introitus.10
located and is associated with sexual functions) Vaginismus is painful involuntary spasmodic contraction of va-
(B) Two lateral triangles (triangle of comforts where normal phys- gina in response to physical contact or pressure, especially while
iological functions are performed) sexual intercourse.11
(C) Posterior or lower triangle of pain (triangle of pathologies Other gynecological conditions include vaginitis (can be
where diseases occur).7 infectious—­
bacterial, fungal, parasitic, or viral or non-­
infectious),
A wide array of conditions can affect the appearance of female post-­
puerperal changes, post-­
surgical changes, and menopausal
external genitalia. These can be broadly divided into 3 classes (Box 1). changes.

F I G U R E 2 Concept of circles and

triangles applied to female genitalia by
Hichem Bensmil [1—­black dotted line
circle—­outermost ring comprising groins
area; 2—­Red dotted line circle—­middle
ring of labia majora; 3—­Intersection of
black dotted lines circle—­inner most ring
of labia minora].
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114 JINDAL et al.

TA B L E 1 Various causes leading to change in external genital of females

1. Physiological changes Pigmentation, hair growth, vascularity

2. Age related changes Laxity, loss of tone, wrinkling, incontinence, prolapse
3. Dermatological diseases Pigmentary disorder (explained in detail below)
Inflammatory disorder -­acanthosis nigricans, hidradenitis suppurativa, lichen planus, lichen sclerosus et
atrophicans, vitiligo, Zoon's vulvitis
Infections—­Fungal—­c andidial intertrigo, Tinea cruris, Bacterial—­staphylococcal, bacterial vaginosis, Protozoal—­
trichomoniasis, viral—­herpes, molluscum contagiosum, condyloma accuminata (human papilloma virus)
4. Aesthetic perceptions Shape, size, color, position
Labia minora hypertrophy, labia majora atrophy, vulvar hyper coloration
5. Functional issues Vague feelings of discomfort, irritation, friction, pain. Perceptions about shape, size, length, orientation,
slacking, and sagging
6. Endocrinological influences Steroidal hormones, estrogens and androgenic influences, obesity, metabolic syndrome
7. Gynecological conditions Vaginal laxity syndrome, vaginal prolapse, pelvic organ prolapse, urinary incontinence, genitourinary
syndrome, postmenopausal syndrome, Vaginismus

TA B L E 2 Various aesthetic concerns of genitalia with their causes

Pigmentary changes Disease Etiology Treatment

Acanthosis nigricans Thickening of skin due to insulin Weight reduction Lifestyle and diet
resistance and upregulation of insulin modification
such as growth factor-­1 (IGF-­1), Vit D analogues
Association with diabetes mellitus, Retinoids topical
gastric carcinoma (rarely) Oral metformin
Er.Yag laser
Postinflammatory Epidermal causes—­infections, dermatitis Topical depigmenting creams
pigmentation Dermal causes –­lichen planus, fixed drug Glycolic acid peels
eruption Q switch Nd.yag laser
Vulvar melanosis Lentigines –­multiple or single brown Excision
colored patches with irregular Cryotherapy
borders over labia majora, labia Q-­switch Nd.Yag laser
minora
Depigmentary conditions Lichen sclerosus et atrophicans, vitiligo Topical steroids, Tacrolimus, Pimecrolimus,
excimer laser, phototherapy, grafting
Hair disorder Alopecia areata Patchy or complete non-­scarring loss Treat as for alopecia areata in other areas
of hair secondary to auto-­immune or a part of alopecia universalis
destruction of hair bulb
Hair removal or hair shaping Congenital or racial IPL, diode, alexandrite or Nd.Yag laser
Absence of pubic hair Hair transplantation

4.2 | Dermatological conditions with aesthetic mentioned in the introduction, this is a multidisciplinary specialty
implications and coordination between these branches, and at times including
a psychiatrist will yield best results.Counseling forms the first step
Some dermatological conditions over the genitalia can primarily towards understanding a woman's motivation toward the cosmetic
have aesthetic concerns, and present to the aesthetic physician/sur- surgery procedure. A careful and thoughtful exploration of women's
geon. These conditions are elaborated in Table 2. autonomy toward the decision of cosmetic surgery procedure and
This list does not include conditions such as growths which are ruling out any possibility of any force, exploitation, and possibility of
entirely pathological and need medical/surgical therapy. depression or anxiety disorder in the patient is needed.12
If a woman raises concerns regarding about appearance of her
external genitalia, the doctor should reassure her that the size,
5 | CO U N S E LI N G shape, and color of the external genitalia varies considerably from
woman to woman. A woman should be explained about the effect of
A dermatologist should be aware of what is in his realm and puberty, pregnancy, delivery, and menopause on the appearance of
what needs to be referred to a gynecologist/plastic surgeon. As external genitalia.
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JINDAL et al. 115

F I G U R E 3 Step-­ladder approach to
vaginal rejuvenation

Before proceeding for the procedure, the possibility of potential 6.2 | Lasers and other energy-­based devices in
adverse effects and expected outcome should be discussed with the aesthetic gynecology
patient.
Conventional uses include Laser for hair removal, for pigmentation
and for skin laxity, just as these are used on face and other parts
6 | A PPROAC H of the body. Hair removal using intense pulsed light (IPL), diode
(810 nm), alexandrite (755 nm), or Nd:yag (1064 nm) can be used for
Any patient needing surgical intervention should be referred to a hair reduction therapy over pubic area, labia majora, or bikini area.
gynecologist, urologist, or a plastic surgeon. Only non-­invasive pro- Unlike laser, IPL is polychromatic, non-­coherent, and non-­collimated
cedures are dealt with here. light with a wavelength of 420–­1400 nm with varying pulse dura-
tions. The main chromophores in the skin are hemoglobin, melanin,
and water, which have a broad spectrum of absorption spectrum;
6.1 | Vaginal rejuvenation hence, IPL can be used for a number of conditions ranging from pig-
mentation to hair growth.
The progressive cessation of estrogen production inside female's body However, in recent times, there has been an explosion of publi-
leads to certain metabolic and tissue changes which are more evident cations on the subject vaginal rejuvenation also called feminine or
in the genital tract. There is thinning of vaginal epithelium, vaginal intimate rejuvenation.
walls become looser with loss of rugosities, looking more pale, dry, and
friable on specular examination. The constellation of these symptoms
is termed as genito-­urinary syndrome of menopause (GSM).13 6.3 | Vaginal rejuvenation by energy devices
Indications for vaginal rejuvenation include vaginal laxity syn-
drome, GSM, and vulvodynia. Vaginal laxity syndrome describes a Management of GSM consists of various non-­pharmacological and
disorder in which there is excessive laxity of vaginal walls, leading pharmacological measures.14,15
to feeling of looseness and decreased sexual pleasure and might be The step ladder approach to vaginal rejuvenation is provided in
associated with incontinence. To enhance sexual pleasure is one of Figure 3. Several energy sources have been used in their non-­ablative
the most common indications for which vaginal rejuvenation is per- mode for inducing vaginal rejuvenation, via both mucosal rejuvena-
formed. Vulvodynia, that is, complex, chronic pain disorder affecting tion and sub-­
mucosal tissue tightening through neocollagenogen-
more than 4–­16% of women.14 esis. Recent advances have introduced special tools for delivery of
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116 JINDAL et al.

non-­ablative lasers and other energy sources to suit the circumferen- neo-­angiogenesis, fibroblast, and neuronal growth. Improved vascu-
tial nature of the vagina and precisely without causing any ablation. larity and neural supply in clitoris and vagina help in achieving better
The principles involved are the selective photothermolysis with water sexual responsiveness and increases sensitivity by increasing blood
present in the vaginal wall acting as a chromophore. so widely used in flow.
skin rejuvenation, with water in the vaginal wall as the chromophore. Platelet rich plasma is also being used for regeneration of vaginal
Mechanism of Er:Yag and CO2 laser—­Chromophore for Er.Yag mucosa, muscles, and skin. After PRP injection, skin becomes thicker
and CO2 laser is water. When water absorbs laser, it generates heat and firmer making the vagina look much more youthful and also the
which stimulates production of heat shock protein in fibroblasts and supporting ligaments and muscles become stronger which helps in
leads to collagen synthesis and possibly elastic fiber synthesis result- alleviating urinary incontinence symptoms.
ing in tightening, generation of new epithelium, and neovasculariza- Runels et al preformed a study including 11 women who were
tion. The temperature of the mucosa is gradually raised to 60–­63 given intravaginal and intraclitoral injections of PRP and they con-
degree, as the rise in the temperature is gradual the chances of burns cluded that PRP can be a beneficial technique in females with sexual
is very low. 60–­63 degree is the optimal temperature for causing dysfunction especially in areas of desire, arousal, lubrication, and
shortening of collagen fibers and neocollagenesis. Er.Yag laser has 10 orgasm.19
times more absorption by water as compared with CO2 laser. Non-­
ablative smooth mode of Er:Yag can be used for vaginal tightening
which causes gradual heating of the vaginal tissue to 60–­63 degree 8 | H YA LU RO N I C AC I D FI LLE R A N D
upto 40–­45 layers of the vaginal mucosa resulting in shortening of LI P O FI LLI N G
collagen fibers. Tightening of vaginal canal can also be achieved with
the use of energy based devices such as radiofrequency (RF).16 8.1 | G–­spot
Recent study has shown that RF increases the small nerve den-
sity in the papillary dermis.17 Post treatment biopsies have shown In 1981, Addiego et al named the vaginal erotogenic zone as the
increased elastin and collagen after RF, elastogenesis after RF is a Granfenberg zone and later on the International media and the pub-
unique feature to vaginal wall which might play a significant role in lic carried it on as G spot. 20
15
re-­establishing vaginal tightening. The existence of G-­spot has been controversial, but with the up-
High-­intensity focused ultrasound (HIFU) energy works on the coming research in last two decades is had been possible to delin-
basis of focused thermal effect produced at 60–­70°C resulting in eate anatomical localization, structure, histological, and functional
cavitation, apoptosis, and thermal coagulative damage of the tissue. features of G-­spot. 20
HIFU was previously used in oncology for tumor removal, has now
made its way into aesthetics for face lift, body contouring, and lip-
olysis and eventually has made its way to aesthetic gynecology and 8.2 | Indications for G-­spot treatment
is being used for vaginal tightening and stress incontinence. The vag-
inal devices are made with same type of transducer as being used for Ostrzenski established a clinical diagnostic criterion for secondary
face lift with 25 mm-­long and 10-­mm wide emission plate made in G-­spot dysfunction including
cylindrical shape for vaginal penetration.
High-­
intensity focused ultrasound releases mechanical waves a. Secondary inability to reach vaginal orgasm
which cause molecular vibration of the water inside the tissue, raising b. Diminished vaginal engorgement
the temperature, and resulting in tissue modification. Without induc- c. Decreased sensation of anterior-­distal vaginal wall during sexual
ing any harm to epidermis and surrounding tissue, HIFU induces neo- stimulation
collagenesis in mid and lower reticular dermis and neoelastogenesis d. History of traumatic vaginal delivery or anterior-­distal vaginal
in deep reticular dermis. In a comparative study between monopolar wall surgery
RF and HIFU, it was concluded that RF impacts tissue in more diffuse e. Prior conservative medical therapy21
18
manner whereas HIFU causes more focal induction of collagen.
G-­spot amplification, aka G-­spot augmentation, or the G-­shot is
a minimally cosmetic surgery procedure for temporarily increasing
7 | PL ATE LE T R I C H PL A S M A ( PR P) A N D the size of the G-­spot believed to be located about halfway between
IT S U TI LIT Y I N G E N ITA L R E J U V E N ATI O N the pubic bone and the cervix. Amplification is done using hyaluronic
acid filler, autologous fat transplant is also employed in few cases
7.1 | O shots injected into the bladder-­vaginal septum. The principle behind the
procedure is increase in size of the spot will increase the amount of
O shots also referred to as “Orgasm shot” is injection of platelet rich sensory input and/or friction leading to increased sexual satisfaction.
plasma into clitoris, vagina, pubocervical fascia, and skene's glands. Hyaluronic acid fillers-­fillers have been used for augmentation of
Platelets after degranulation release growth factors which cause deflated or atrophic labia majora and labia minora.
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JINDAL et al. 117

8.3 | Lipofilling • Provide fully informed consent.

• Inform women about normal genital variations.
Adipose-­derived stem cells (ADCs) are an enriched source of stem • Suggest psychological intervention for problems such as body
cells available in surplus amount. The chances of rejection of au- image distress.
tologous fat transfer are negligible. It has varied composition with • Be aware that surgeons are performing procedures that lack a
main constituents being stromal vascular fraction (SVF), including clear evidence base.
ADCs, extracellular matrix (ECM) endothelial cells, and other im- • Do not perform FGCS on women and girls under 18 years of age,
mune cells. irrespective of consent.
Fat transfer is performed to restore the genital volume, rejuve- • Advise women about the risks of FGCS and the lack of reliable
nation of vulvar skin, and vaginal walls by lipofilling. Lipofilling con- evidence concerning its positive effects.
sist of reducing vaginal diameter by increasing thickness of labial • FGCS should not be provided by the National Health Service.
folds by fat transposition.19
American College of Obstetrics And Gynecology (ACOG)

9 | B OT U LI N U M TOX I N • Female cosmetic genital surgery (FCGS) is not medically indicated,

nor is there documentation on its safety and effectiveness.
Botulinum toxin are protein-­
based neurotoxins produced by an- • Inform women about the lack of data supporting the effective-
aerobic sporulated bacteria of the Clostridium genus, which acts ness of FGCS, as well as about the potential complications.
by paralyzing the muscle by blocking the pre-­synaptic release of • Evaluate for sexual dysfunction all women requesting FGCS to
acetylcholine (neurotransmitter). They have been utilized in case of improve sexual functioning and consider other non-­surgical inter-
treatment resistant vaginismus and vulvodynia. 22 Vaginismus de- ventions (e.g., counseling)
scribes the involuntary, recurrent perineal muscle contraction which • Consider ethical issues associated with the marketing and fran-
occurs during sexual intercourse. Varying doses of botulinum toxin chising of FGCS.
has been used from 100 units to 500 units depending on the grade
of vaginismus, under sedation into levator ani muscles. Pacik PT AU T H O R C O N T R I B U T I O N S
et al conducted a retrospective study including 241 patients who Anuradha Jindal involved in main manuscript writing, research for
were treated with multimodal approach using botulinum toxin and the manuscript, and making figures and tables for the manuscript.
progressive dilation with conscious sedation. Seventy one percent Venkataram Mysore performed data collection, manuscript editing,
of the patients reported improvement with ability to have pain-­free and framework of manuscript. Jayashree Venkataram final frame-
23
intercourse in 5.1 weeks median time. work and editing of manuscript, expertise opinion.
Vulvodynia is characterized by burning pain in the vulvar area,
persistent for at least 3 months, in the absence of other relevant der- DATA AVA I L A B I L I T Y S TAT E M E N T
matologic or neurologic findings. 20 to 40 units of Botulinum toxin The data that support the findings of this study are available from
has been found useful when injected into vestibule, perineal body the corresponding author upon reasonable request.
and levator ani muscles. Session can be repeated after 2 weeks if
patient has persistent complains of pain. 24 E T H I C A L A P P R OVA L
Meta-­analysis has shown that boutlinum toxin is a useful tech- The authors confirm that the ethical policies of the journal, as noted
25
nique for patients not responding to usual line of treatment. on the journal's author guidelines page, have been adhered to. No
ethical approval was required as this is a review article with no origi-
nal research data.
10 | S U RG I C A L M E TH O D S
ORCID
Surgical techniques are sought for labial reduction in case of labia Jayashree Venkataram Mysore https://orcid.
major and labia minora hypertrophy. Clitoral hood reduction or re- org/0000-0001-7858-6249
duction of clitoris length, hymenoplasty, and vaginoplasty are some
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