BACKGROUND: Despite high complication rates, patients persistently present for single-stage augmentation mastopexy. In empty, deflated breasts, we perform one-stage augmentation mastopexy; however, in heavy ptotic breasts, our preference is to stage the procedure with mastopexy and fat graft first. With volume from fat grafting focussing on the upper pole and cleavage areas, many of our patients avoid implants altogether. This reduces subsequent risks of waterfall deformity, implant displacement, rupture and a lifetime of implant exchanges. OBJECTIVES: We aim to describe our findings and technique for reducing progression to the second stage of a two-stage augmentation mastopexy with the appropriate use of moderate to high volume of fat grafting at the primary operation. METHODS: This is a retrospective review of all patients who presented to the senior author (KT) requesting breast implants and requiring mastopexy, from January 2018 to December 2022. RESULTS: Over the five-year period, 137 patients were identified. Seventy-one (51.8%) underwent single-stage augmentation mastopexy, 55 (40.1%) underwent mastopexy with fat grafting and 11 (8.0%) underwent mastopexy with no fat grafting. Our key finding in this study is that 52 of 66 (78.8%) of planned staged patients, who underwent mastopexy with or without fat grafting, were happy with the volume attained and no longer wished to undergo further implant augmentation. CONCLUSION: In selected patients, appropriate volume and position of fat grafting at the time of primary mastopexy can significantly obviate the need for a second stage implant (alloplastic) augmentation. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .