Has anyone done reconstruction without the tissue expanders?

Yes, working through everything now. No nipple sparing here. My onc wouldn't support bilateral, so I only had uni and will reduce opposite side to match next year. My ps did one-step at time of reconstruction. May not have actually been Alloderm, but it was some form of the similar mesh (may have used Strattice). I did not specifically request this approach, it was the surgeon's idea and I think the reason had mostly to do with the huge amount of skin I had from being so large breasted in the first place allowing him to reduce the risk of this approach. He went into the reconstruction not sure what solution he would end up with and had the implants and TE's with him in surgery. Besides the mesh hammock, he also doubled over the flap of skin for extra protection for the implant. He was especially concerned about the drain rubbing against the implant during recovery as well as the risk of bacteria reaching the implant. This was his biggest concern and the risk of necrosis to the outer skin was he minimized the risk of bacteria getting to the implant by using the inner flap of skin. Unfortunately, at the very ends of the doubled-over skin flap was where the skin was colored blue from the sentinel node biopsy, and he had a very difficult time telling what was viable way off at the distant ends. At my one-week post-op checkup, there were signs of necrosis in those distant reaches and we opted for the aggressive solution of going back up into surgery and letting him address that concern. When he went back in and took care of all the skin that was dying or didn't look viable, the amount he had left to pull back over the implant was just a little too taut for his comfort and he decided to pull out the implant and replace it with tissue expanders. The skin is still almost completely doubled-over inside except for one small half-moon area where the under-skin is exposed and will become the outer skin. He is much happier with the way this is healing. Because of the complication, I ended up having to go back into surgery to address the necrosis and I will have to have another surgery to put an implant back in after the TE fills are finished which I wouldn't have needed if the one-step had worked for me. I don't begrudge the decisions the plastic surgeon made, though. I know he had my best interest in mind by going with the one-step and I'm glad I had the opportunity, even for only a week, to see what I looked like and how it felt to have the implant in. Not too many people get that opportunity and I thought it was cute! The TE's are more painful than the implant was IMHO and I haven't even started the filling yet.The drain could also come out sooner because PS is fine with aspirating any fluid build-up that remains with TE, but risk was too great with implant.

I can't even begin to address the nipple sparing discussion. I can only say that I wouldn't have considered it in my own situation and therefore have never even looked into it as an option. My surgeon made a lot of accomodations to minimize the risks of contracture and damage to the implant during recovery since the implant is far more at risk than the TE's. Make sure your PS explains these concerns to you and that you are happy with how they are being addressed in your particular procedure before you decide to go one-step.

Best of luck with whatever you decide and prayers for a pathology report that brings you peace!