In the public mind it is strongly associated with the kind of plastic surgery that anyone would celebrate, the medical advances which mean that awful disfigurements, or even smaller ones that cause genuine mental distress, can now be corrected. It is a Good Thing. So women who have cosmetic surgery to please themselves, and the surgeons who operate on them to facilitate that pleasure, must be a Good Thing as well. Certainly that is the reassuringly uncomplicated argument that women have been folding to their breasts in ever-larger numbers. A cosy arrangement which is harmful to no one.
Where, then, does the case of Steven Hoefflin slot into this scenario? One of Hollywood's most successful cosmetic surgeons, Hoefflin is presently being investigated by the Medical Board of California, following a raft of accusations against him by four female ex-employees. The women - Barbara Maywood, Lydia Benjamin, Kim Moore Mestas and Donna Burton - have made a variety of allegations against Hoefflin. But it is the testimony of Maywood, who was Hoefflin's theatre assistant for 17 years, which is the most revolting.
Angie Everhart, it is alleged, had booked into Hoefflin's clinic for a minor breast enlargement in 1995. Since she is a dazzlingly beautiful woman with a body that most people would consider to be pretty much perfect, her desire for such an operation is baffling. But what happened after she'd been taken into theatre and put under anaesthetic is utterly chilling, and a clarion call to all women who find the vogue for breast surgery unsettling.
As Everhart lay unconscious on the operating table, her then boyfriend Sylvester Stallone wandered in, uninvited, unauthorised and unscrubbed. Maywood ordered him out of the room, but he put on a mask and gown and returned. It is then alleged that Hoefflin asked the actor "how he wanted them".
Stallone, Maywood testifies, replied: "Big but perky, kinda like a 17- year-old."
When Everhart came round from the operation, she found she had been given not the small alteration she'd asked for herself, but, instead, that requested by Stallone. She later had the operation reversed, but not before giving Stallone, whom the model-turned- actress was supposed to be marrying, his marching orders.
The incident suggests that while women may claim that they've had breast enlargements for themselves, at least one surgeon assumes that it's to please their man. Other accusations are no less unsettling, suggesting that Hoefflin held his patients in utter contempt and viewed his female staff, as well as his clients, as sex objects and cash cows.
Michael Jackson, it is alleged, was tricked into believing that he'd had surgery by the simple expedient of putting him under an anaesthetic, then changing the clocks before he came round. Elizabeth Taylor, in for a face-lift, was stripped naked and described as "this old stuff". Tax evasion, drug abuse and sexual harassment have also been dropped into the bewildering mix of allegations.
It would be reassuring for many to see the Hoefflin case as simply another tale of Hollywood dysfunctionality, in which people with more money than sense are held up to the public ridicule that they deserve. Here is a man who is such a "friend to the stars" that they have nicknamed him "Doc Hollywood". Now they are in the shocking process of finding out exactly who their friend is. But since California's cosmetic surgery culture has caught on across the West, the attitudes revealed in this case bear further scrutiny. For though Hoefflin has been rather too vocal in his contempt for the people he is supposed to be guiding towards self-fulfilment, he is not alone in feeling that way about his "trade".
In Britain, too, the behaviour displayed in private cosmetic surgery clinics suggests cavalier attitudes to the mental and physical health of patients. In an undercover investigation in 1997, Health Which? researchers consulted seven clinics that had advertised in glossy women's magazines. An investigator enquiring about breast reduction surgery was told at one clinic: "It's not a major operation, not major surgery." But it's a three-hour operation, with a three-month recovery time, and, as in all operations, there are risks, as the list of botched breast operations put right by the NHS can attest.
Another researcher asked about buttock and thigh liposuction (surgical fat reduction is currently the most popular cosmetic operation in Britain, with breast surgery second, and face-lifts third). She was told by a surgeon that she also had a "reasonable bulge around her abdomen and on her knees," and that he could "flatten them down a bit more too," for more money. At another clinic, when the same researcher pressed about the health risks involved with this operation, she was told, misleadingly, "on a scale of one to 10 of dangerousness, it's about one". When she asked about the pain and discomfort she might expect, she was told it was "nothing a few paracetamol wouldn't ease." Tell that to Eda Watson, who won an out-of- court settlement of pounds 20,000 after surgery to remove fat from her hips resulted in constant severe pain. After corrective surgery, which also went wrong, she discovered that her surgeon had no specialist qualifications, but did have a criminal record for illegally obtaining morphine and smashing a glass in a man's face.
Nasty stuff, and particularly worrying since two years on from that report there is still precious little regulation of this burgeoning industry, which, it is predicted, will be worth pounds 250m a year in this country alone within five years. Surgeons need no specialist qualifications, and anyone can set up as a private counsellor with no qualifications at all. While it is supposed to be up to the General Medical Council to control and discipline private doctors, in practice it's difficult to find out which doctor is responsible when things go wrong. And since clinic owners and managers are unlicensed, they cannot be held accountable to the doctors working for them.
Several MPs, particularly Ann Clwyd, have campaigned for years for action to end the string of cosmetic surgery scandals. Thankfully, after years of unchecked growth, there is going to be an official inquiry into private clinics, during which MPs will study calls for much tougher regulation on private clinics. This move is likely to result in some protection for lambs to cosmetic slaughter, not to mention those for whom cosmetic surgery really is essential to mental health and happiness. But no one can legislate against the attitudes of those who seek out needless cosmetic surgery and those who are happy to provide it.
Women who, like Pamela Anderson, are considering surgery "just to please themselves" should sit down with a video of the performance artist Orlan before they head for any clinic, regulated or unregulated. For years Orlan has been subjecting herself to public cosmetic operations in which she is given surgery to make parts of her face and body resemble the features of history's great beauties. She is not aiming to become more attractive, and admits that she is disfiguring herself. She expects, when the years of operations are over, to find herself not more beautiful, but uglier. It is difficult to work out what her motivation might be, beyond self- abnegation. Which is what she has in common with any woman who adjusts her breast size just because she imagines that she's the person who fancies it.