With the increasing demand of breast augmentation with fat grafting in the past decade, the techniques of fat grafting have been continuously improved or refined and the science behind has been extensively investigated. Therefore, the safety and efficacy of fat grafting to breasts have met the standard for primary breast augmentation. The key to a successful outcome and reducing fat necrosis is meticulous fat harvesting, graft processing, and injection. In this article, authors propose our preferred techniques of primary breast augmentation with fat grafting and an algorithmic approach for the management of fat necrosis based on the most scientific studies.