Background <p>Prepectoral direct-to-implant (DTI) breast reconstruction is currently the most widely used implant-based reconstruction method, which often utilizes an acellular dermal matrix (ADM)-assisted approach. There are two primary methods for applying ADM: full coverage of the implant and anterior tenting, where only the front is covered. Despite the widespread use of these techniques, comprehensive studies comparing their outcomes are lacking. This study aimed to conduct a thorough head-to-head comparison of the outcomes of the two methods.</p> Patients and Methods <p>We reviewed patients who underwent prepectoral DTI breast reconstruction with ADM between January 2021 and April 2022. The patients were divided into two groups on the basis of the preference of the attending surgeon: full coverage and anterior tenting. Postoperative complications and esthetic outcomes were compared and analyzed.</p> Results <p>A total of 304 patients (363 cases) were analyzed: 295 in the full-coverage group and 68 in the anterior tenting group. The baseline characteristics were generally similar between the two groups. Overall complications did not show significant differences, whereas the capsular contracture rate was significantly lower and detected later in the full-coverage group, which remained significant even after adjusting for other factors, including radiotherapy. The esthetic scores were similar between the groups; however, rippling was significantly less frequently observed in the anterior tenting group.</p> Conclusions <p>Our findings indicate that both methods of applying the ADM yield comparable outcomes, each with its own advantages and disadvantages. Selection of an appropriate method based on a specific situation can lead to optimal outcomes.</p>