Respect for patient autonomy, as a fundamental principle in contemporary bioethics, guides the process of informed consent through which, it is hoped, patients' wishes are determined and executed. However, when procedures are exclusively cosmetic, questions as to the ethical legitimacy of such requests and enhancements arise. The purpose of this article is a thorough evaluation of the notions of and tensions inherent to the practice of autonomy and informed consent as they apply in aesthetic surgery. The question of motivation to undergo enhancement will be discussed, as well as the significance of risk and competence in determining the legitimacy of choice. The final conclusion is that the complexity of the moral issues involved requires conceptualization of an expanded notion of responsibility, which recognises that we need to progress beyond a 'legal' to a 'moral' conception. The implications of this expanded notion of responsibility are discussed.