I had both breasts removed and did not have any cosmetic reconstruction although I had to have a diep flap because there was not enough skin left after my mastectomy to close the wound.
The reason I chose a bilateral mastectomy was symmetry. I didn't want to have to try to match the removed breast to the remaining breast. As it turns out, since I had to have the diep flap on one side, I still don't have that symmetry, but I still prefer that over full reconstruction.
Even without reconstruction, I had 5 surgeries to remove the cancer with clean margins and to close the wound. The last surgery, which was the flap transplant was by far the longest and most complicated. The primary concern is being able to establish a new blood supply to the transplanted flap so the transplanted tissue does not die. Fortunately, mine did take and has healed quite nicely.
I had considered at one point of either having the flap removed or getting a cosmetic flap for the other side, but at this point, I am use to the way it is and really can't see going through more surgery just for that. .