Immediate breast reconstruction following mastectomy improves quality of life with benefits observed in body image and psychological health. An implant based reconstruction is one of the most common options utilised and a successful outcome relies on careful patient selection and technical decisions made intraoperatively. Significant technological adjuncts has advanced the role of direct to implant reconstruction by reducing rates of complications and implant failure. Understanding past techniques and variables in current practices facilitates operative management to provide an optimal implant based reconstructive outcome.