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Background: Immediate prepectoral implant-based breast reconstruction (IBR) following skin-reducing mastectomy (SRM) preserves the pectoralis major muscle, improving recovery and aesthetics. A dual-layer technique combining porcine-derived acellular dermal matrix (ADM) with an inferior autologous dermal sling may enhance implant support, vascularization, and lower-pole stability, particularly in patients with macromastia or ptosis. Methods: This retrospective single-center study included 20 patients (24 breasts) who underwent SRM with immediate prepectoral IBR using the dual-layer technique between January 2023 and May 2025. Demographic, oncologic, and perioperative data were collected prospectively. Complications were classified by severity, and patient-reported outcomes were evaluated using the BREAST-Q scale preoperatively and at 1, 3, 6, and 12 months postoperatively. Statistical analysis included paired t-tests, Shapiro–Wilk tests, and effect size estimation (Cohen’s dz). Results: Mean age was 42 ± 6.3 years and BMI 26.1 ± 3.2 kg/m². Mean mastectomy specimen weight was 432.5 ± 120.8 g, and implant volume 375 ± 60 cc. No reconstruction failures or infections occurred. Early complications were reported in 20.8% of breasts, including superficial nipple–areola complex epidermolysis (8.3%), seroma (4.2%), and hematoma (4.2%), all managed conservatively. At 12 months, BREAST-Q scores improved significantly: satisfaction with breasts increased from 63 ± 8 to 89 ± 11 (p < 0.001); psychosocial well-being from 60 ± 10 to 81 ± 11 (p < 0.001); and physical well-being from 62 ± 7 to 82 ± 10 (p < 0.001). Conclusions: Dual-layer prepectoral reconstruction using porcine ADM and autologous dermal sling is safe, provides durable implant stability, and significantly improves patient satisfaction and quality of life following SRM. Full article