BACKGROUND: Secondary procedures following breast augmentation are often more difficult than primary cases because the soft-tissue envelope changes over time. OBJECTIVES: This study was conducted to confirm the utility of a composite technique in breast revisional surgery. METHODS: This was a 9-year retrospective chart and photographic data study of one surgeon's experience with the combined use of fat and implants in revisional cases. The 148 patients had a follow-up at least 1 year after surgery. Our approach consists of a detailed analysis of the different layers covering the implant and yields a treatment plan addressing all issues involving the secondary breast. RESULTS: On average, revisional surgery was performed 8.66 years after the first augmentation. The mean age of the patients at revision surgery was 42 years (range, 22.2-70.7 years). The mean fat harvest was 600 mL (range, 100-3000 mL) and the mean volume of fat reinjected was 153 mL (range, 60-400 mL). The mean volume before and after revision was the same (288 mL vs 289 mL). At the original surgery, the breast implants were located in a subpectoral pocket in 78.7% of the patients and, at the revision surgery, in a subglandular pocket in 74.8% of the patients. Within the first 2 years, 13 patients (8.7%) underwent reoperation for additional fat grafting. Among 45 preoperative breast capsular contractures, there were 8 recurrences in the first 3 years resulting in 4 reoperations. CONCLUSIONS: Secondary breast augmentation cannot rely solely on implant exchange. Because the soft-tissue envelope also ages over time, fat grafting is mandatory in the vast majority of secondary cases. A rigorous preoperative analysis enables breast defects to be treated appropriately.