Breast augmentation is one of the most commonly performed cosmetic surgical procedures in the United States. Modern breast augmentation has evolved with the development of various implant options, as well as surgical techniques. To achieve ideal result, it is important for the surgeon to develop a systematic approach to evaluate each patient. The 5 key steps in determining the best surgical plan include: (1) assess the need for concurrent mastopexy, (2) implant selection, (3) pocket plane, (4) inframammary fold position, (5) choice of incision. The purpose of this review is to discuss the principles behind each of these key concepts and how to utilize them in achieving the optimal outcome in breast augmentation.