Background: Plastic surgery has undergone a profound ethical evolution, moving from largely paternalistic, appearance-driven interventions to a practice grounded in patient autonomy, psychological wellbeing, and responsible resource use. Methods: A narrative ethical and historical review was undertaken, drawing on core plastic surgery ethics literature and major historical analyses of cosmetic surgery. Themes examined included changing concepts of autonomy, benefit and harm, and the social drivers of demand for aesthetic procedures. Results: Early cosmetic and reconstructive procedures were often justified by surgeon-centred assessments of “deformity” and social normality. Over the 20th century, the rise of bioethics and principlism reframed plastic surgery decision-making around respect for autonomy, beneficence, non-maleficence and justice. In aesthetic surgery, this generated tension between honouring patient choice and guarding against exploitation, unrealistic expectations and body-image pathology. Parallel historical work has shown how societal norms regarding gender, race and beauty helped normalise cosmetic surgery and shaped which bodies were seen as in need of correction. More recently, debates about publicly funded plastic surgery have focused on functional benefit, psychological morbidity, and distributive justice, asking when aesthetic or reconstructive gains merit allocation of limited health resources. Conclusion: The ethical discourse in plastic surgery has shifted from surgeon-driven normalisation toward a more nuanced balance of autonomy, harm minimisation and fairness. Ongoing reflection is required as new technologies, changing beauty ideals and global surgical practice continue to challenge ethical boundaries.