Excess thigh laxity is a problem for many patients following significant weight loss. Thigh laxity has both vertical and horizontal components that require correction to optimize the aesthetic appearance of the thigh. The vertical vector is best corrected first with a lower body lift or extended abdominoplasty. The remaining loose skin in the medial thigh can then be removed using a horizontal vector resulting in a vertical incision. Residual vertical skin excess is also removed parallel to the groin crease. This article describes the author’s surgical approach and management of medial thigh deformity in the significant weight loss patient.