Goals/Purpose: Management of breast ptosis in patients requiring augmentation is still considered as an interesting and controversial topic. Primary augmentation mastopexy requires pocket dissection as well as skin and parenchymal re-arrangement which could devascularise the nipple areola complex. Adding a large size implant to the breast dissection adds a level of complexity to this problem. On the other hand secondary mastopexy following augmentation is associated with even increased morbidity due to the combined effect of implant presence on the parenchyma and skin blood supply. The goal of this study is to examine the safety and efficacy of this procedure in a group of patients who underwent primary augmentation mastopexy where predominantly large implants were used. Methods/Technique: This study represents a retrospective review all women who underwent primary augmentation mastopexy over the 4 year period from October 1st 2005, and September 30th 2009. In addition to standard demographic data and post operative morbidity, photographic documentation was obtained pre-operatively and at regular intervals during the post operative visits. Results/Complications: During the 4 year period of this study 88 patients underwent primary augmentation mastopexy using different techniques. Fifty two patients had a circumaereolar mastopexy and 36 patients underwent vertical mastopexy. The mean follow-up was 15 month (range 1 to33 months). The average implant size used was 450cc (range 350 to 600). The average nipple to notch distance was 27 cm (range 23 to 35). Most patients in this study had a grade 2 ptosis (n=62), 26 patients had a grade 3 ptosis. The dual plan subpectoral plan was preferentially used in most patients (n=59). Most patients elected to use saline implants (n=63). Six patients (6.8 %) required mastopexy revision for recurrent ptosis or for insufficient lift perceived by the patient. Three patients (3.5% %) underwent revision unrelated to ptosis recurrence; two patients for capsular contraction and one patient for spreading of the aerolar scar requiring revision of the purse string suture. There was no incidence of nipple necrosis, infection or hematoma in this series. Conclusion: Primary mastopexy augmentation technique continues to be a challenging surgical technique. Review of this series of patients revealed a mastopexy revision rate of 6.8% percent and overall rate of morbidity of 10.5 percent. The main caveat in performing this technique is to carefully consider the potential adverse effect of breast reshaping together with pocket creation. In this series the subpectoral plan was used preferentially to maintain additional vascularity to the breast parenchyma. Minimal undermining of the breast parenchyma was done in all cases. The superior pedicle and central vasculature were always maintained in all cases. The addition of the modified purse string technique insured better control of aerolar diameter. With thoughtful planning and accurate operative techniques the risk of serious complications could be avoided. However, the data from this series as well as previous published studies point to the fact that the main morbidity from this procedure is related to the recurrence of ptosis as well as the need for multiple operations.