Introduction: Aesthetic surgery of the medial thigh continues to be a challenging area for surgical rejuvenation. This paper outlines the importance of preoperative assessment and classification and includes new modifications for the massive weight loss patient. Methods: All medial thigh lifts performed from 1999 to 2004 were identified. The type of medial thighplasty was based on the degree of skin laxity and lipodystrophy. Each patient was assigned to one of five separate categories of medial thigh deformity and were evaluated for the outcome of the medial thigh lift and for complications. In addition our recent modifications in techniques were reviewed. Results: 29 patients underwent a primary medial thigh lift. (12 of were massive weight loss patients). 4 patients presented with minor wound dehiscences (17%), 3 with prolonged postoperative edema (12.5 %), and 1 patient with scar widening (4%). Finally, 2 patients in this group underwent a subsequent secondary medial thigh lift (8%). Conclusion: The medial thigh lift is a powerful technique. However,in order to maximize the opportunities for success one must identify to type of medial thigh problem and tailor the operation according to the type of thigh encountered.