BACKGROUNDS: We aimed to assess the feasibility and outcomes of immediate breast reconstruction with prepectoral direct prosthesis placement under the skin envelope in patients with small-to medium-sized breasts with immediate lipofilling of the skin cover. METHODS: Demographic and clinical data of female patients with small-to medium-sized breasts diagnosed with breast cancer who were eligible for skin-sparing mastectomy and immediate reconstruction were included in this retrospective study. Information concerning the surgical technique, implant size, procedure duration, and intraoperative complications were also obtained. All early or late postoperative complications were recorded. Postoperative patient satisfaction was routinely assessed using the Kyungpook National University Hospital Breast Reconstruction Satisfaction Questionnaire. RESULTS: The study included data from 52 female patients (mean age: 49.1±8.6years); the mean follow-up was 30.3 ± 9.7 months. Reconstruction was successful in 50 (96.2%) patients. Capsule contracture developed in 11 patients (21.2%), with six requiring capsulectomy. Three patients (5.8%) showed a slight reduction in the range of motion, mainly due to axillary procedures. Two patients (3.8%) developed rippling that was treated successfully with delayed lipofilling. Forty-eight patients (92.3%) showed postoperative satisfaction, with three being satisfied only after the management of postoperative complications. CONCLUSIONS: The prepectoral technique for breast reconstruction without mesh support is an effective option in patients with small-to medium-sized breasts. This approach has few complications and offers high postoperative patient satisfaction at a reasonable cost. Proper patient selection is necessary to achieve favorable outcomes, and immediate lipofilling improves the results. Moreover, immediate lipofilling seems to improve outcomes of prepectoral breast reconstruction; however, future studies are required to support this finding. LEVEL OF EVIDENCE IV: 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 .