Management of the breast following massive weight loss for both reconstructive and aesthetic reasons poses unique challenges that are often inadequately addressed with traditional techniques. The breast mound is often unstable and deflated, with a loose inelastic skin envelope and ill-defined boundaries that blend into similar lateral chest wall, arm, and upper abdominal contour irregularities. Because this has become more common recently with the increasing prevalence of massive weight loss patients desiring body contouring, the purpose of this review was to discuss modifications to traditional breast techniques that have been proposed for these patients. It has become apparent that mammaplasty techniques in the massive weight loss patient should rely more on extensive glandular manipulation for shape preservation rather than relying on the skin envelope for shaping. Such techniques include parenchymal plication, suspension, and autoaugmentation. This will improve the likelihood of maintained shape and symmetry in an otherwise difficult patient population.