Abstract Introduction Mastectomy for breast cancer may bring the patient to develop long term issues concerning the psychological and physical status. Immediate breast reconstruction (IBR) should be considered and proposed by physicians as an integrated procedure in the surgical approach to breast cancer to reduce further surgery. Acellular dermal matrix (ADM) has been used in revision breast reconstruction for fold malposition, capsular contracture and rippling also, showing good outcomes with low risk of complications. Aim of this study was to verify if the known advantages in using ADM for IBR would led to lower rates of seroma formation, infection, skin flap necrosis and overall complication related to the implant. Methods We performed a prospective study, including all consecutive patients undergone to IBR with biological graft with ADM between January 2012 and January 2013 at our Institution. Data on major issues of the patients and complications were recorded. All patients underwent to IBR with ADM (Tutomesh) implant with or without fibrin sealant positioning. Results A total of 24 patients underwent 28 immediate breast reconstruction with Tutomesh ADM implant. Main postoperative complications included seroma formation in 20.8% (5 pts), infection in 8.3% (2 pts) and hematoma in 4.2% (1 pt). There were any skin flap necrosis in the study. Diabetes was associated in two cases with edema and ecchymosis; hypertension with infection in one case (implant removal) and seroma in one case. First class of obesity (BMI 30–32.7) was associated with seroma in 3 cases, and with infection in one. In patient without fibrin sealant (12 patients – 13 breasts) complications were represented by hematoma (1 pt. 4.2%), infection (1 pt. 4.2%; implant removal) and seroma (4 pts 16.8%). Conclusions The use of Tutomesh® bovine pericardium for immediate breast is safe and technically useful. Complications rate is not high, except for seroma formation that can be reduced by the contemporary use of fibrin sealant.