After massive weight loss the breasts change in numerous ways. The first most obvious change is loss of volume. Typically loss of volume alone can be fairly easily addressed. However, in the presence of massive weight loss excess skin is not only a significant factor but sometimes problematic. Adequately reducing the skin envelope while leaving behind skin to allow for an aesthetic breast shape require skill, expertise and experience. This 42 year old woman who had lost 90 lbs needed a surgeon who possessed all of these attributes. Implants also need to be chosen carefully with numerous sizes, shapes and projections available. Our surgeons go to surgery with an idea of the approximate size and projection of the implants needed. Once in surgery various of the chosen sterile sizers are placed in the breast pocket that is created until an adequately filled skin envelope that does not appear “over-stuffed” is achieved. Then the appropriate implant is chosen. In this case a 325 cc implant with a moderate plus projection was the implant of choice. Using a carefully customized circumvertical skin excision and smooth round gel implants a lovely result was obtained. This very happy patient is only six weeks out from her breast augmentation with a lift however she shows a promising result.