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Aims: We present our experience of direct to implant breast reconstruction with total musculofascial coverage, without the use of ADM., Background: The prevalence of one-stage breast reconstruction with silicone implants has increased markedly in recent years. This is attributed to advances in the surgical technique of mastectomy and to the increased rate of preventive mastectomy. The use of Acellular Dermal Matrix (ADM) became a common practice. Notwithstanding, ADM utilization may lead to higher postoperative complication rates., Methods: Between 2015 to 2018, a prospective study was conducted at the Sheba Medical Center including all patients undergoing mastectomy and immediate breast reconstruction. In this study, we included patients who underwent direct to implant reconstruction with total musculofascial coverage, without the use of ADM. We gathered demographic, oncologic and surgical features, including post-operative complications, along with aesthetic outcome., Results: A total of 20 patients (25 breasts) underwent direct to implant breast reconstruction with total musculofascial coverage. The overall complication rate was 24% (6 breasts). Minor complications (5 breasts, 20%) were manifested as delayed wound healing, minimal capsular contracture, skin necrosis and minor infection. A major complication of capsular contracture occurred in one patient. Corrective surgery due to aesthetic outcome was offered to 36% of the patients. nevertheless, only 16% chose to undergo an aesthetic reoperation., Conclusions: Immediate direct to implant breast reconstruction with total musculofascial coverage is an attractive option for single stage breast reconstruction with excellent aesthetic outcomes and low complication rates. Presumably, with a careful patient selection, the complication rates can be reduced even further.