Background <p>Few studies have evaluated prepectoral implant reconstruction without acellular dermal matrix (ADM) or mesh, and most reported only short-term outcomes. This study, with long-term follow-up, reports the outcomes of prepectoral direct-to-implant reconstruction following mastectomy without the use of ADM or mesh.</p> Methods <p>Patients who underwent prophylactic or therapeutic nipple-sparing mastectomy with immediate prepectoral implant reconstruction at our institution between 2018 and 2025 were included. Patients with locally advanced breast cancer or those who underwent tissue expander reconstruction were excluded.</p> Results <p>A total of 32 breast reconstructions were performed in 25 patients. The mean age was 39 years, and the median follow-up was 38.5 months. Implant loss occurred in two cases (6.2%), both in smokers. Significant capsular contracture developed in four breasts, all of which had received radiotherapy. Rippling occurred in three cases (9.4%), none requiring intervention. The overall satisfaction rate (very good and good) was 90.6%.</p> Conclusion <p>Prepectoral direct-to-implant reconstruction without ADM or mesh yielded favorable outcomes while being technically simpler and less costly than techniques using those materials. The overall complication rate was acceptable, with excellent results in non-radiated patients. In the radiated group, although capsular contracture occurred in approximately one-third of cases, patient satisfaction remained high. Thus, prior or anticipated radiotherapy should not be considered an absolute contraindication to this approach.</p> Level of Evidence IV <p>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 <a href="http://www.springer.com/00266">www.springer.com/00266</a>.</p>