Post-bariatric plastic surgery has progressed from an obscure topic to the fastest growing area of our specialty. Care of these patients involves unique clinical and socioeconomic challenges. The authors describe the factors inherent to the care of these patients, and propose a “center of excellence” approach as a means of effectively addressing the challenges involved. The authors report their experience building a specialized center for massive weight loss patients in an academic setting. Patient care algorithms used in the center are described, as well as technical advances in breast reshaping, correction of back rolls, and buttock shaping. A retrospective chart review of 299 patients undergoing 692 procedures by a single surgeon (first author of this manuscript) over a 2.75 year period demonstrated a high incidence of local wound complications, but low systemic morbidity. Plastic surgery after massive weight loss is an evolving field that has a dramatic impact on the lives of patients. Careful patient evaluation and selection will help maintain safe practice in this new subspecialty.