The authors begin their discussion of current concepts in massive weight loss (MWL) surgery by offering terminological guidelines that help define reconstructive and aesthetic concepts and procedures for the post-MWL patient. Measures for effective preoperative nutritional and metabolic screening include assessment of weight fluctuations over time, constitutional symptoms, and medications and nutritional supplements. Although there is no established body-mass index (BMI) threshold above which surgery should be refused, higher BMIs have been associated with increased complications. Residual medical problems and psychosocial issues require assessment before surgery, with appropriate specialist consultation as necessary. Consultation with patients concerning the different expectations for functional versus aesthetic procedures and issues such as postoperative scarring and the common incidence of wound healing problems is essential. Patient safety is paramount in decisions to combine multiple procedures and plan stages. The authors often recommend combining abdominoplasty and mastopexy. Surgeon experience, operative setting, and a patient's medical status are factors which influence how much surgery should be performed in the same operative setting. Centers of Excellence in body contouring that provide a team approach combining comprehensive patient evaluation, outcomes research, and surgical training may be the optimal approach for treating the massive weight loss patient.