Background: Outcomes in primary breast augmentation depend on careful preoperative planning and clear communication between patient and surgeon. Three-dimensional imaging with computer simulation is an evolving technology with the potential to enhance the preoperative consultation for patients considering primary breast augmentation. The purpose of this study was to prospectively evaluate the impact of three-dimensional imaging with computer simulation on patient-reported and objective, mammometric outcomes in women undergoing primary breast augmentation. Methods: One hundred patients were enrolled in a prospective trial with randomized and nonrandomized arms. The randomized arm was composed of a control group consisting of patients who underwent tissue-based planning without simulation (n = 13) and an intervention group consisting of patients who were simulated (n = 10). The remainder constituted the nonrandomized group who specifically sought pre-operative simulation. Patient-reported outcomes (BREAST-Q) and mammometric data were recorded and compared preoperatively and 6 months postoperatively. Results: Over time, significantly more patients refused randomization and chose simulation (p = 0.03). Breast augmentation led to substantial improvements in satisfaction with breasts, sexual well-being, and outcome. Simulation, however, did not significantly impact patient-reported outcomes or mammometric parameters. No strong correlations were identified between patient-reported outcomes and mammometrics. Conclusions: Patients are likely to use novel technology such as three-dimensional photography with computer simulation if they perceive it to enhance their understanding of their final outcome. These patients may seek out practices specifically offering such technology. Incorporation of simulation into the preoperative consultation, however, did not lead to clinically meaningful changes in patient-reported outcomes.