According to the literature, breast cancer located in the central area of the breast accounts for 5 to 20% of all breast cancer cases [10, 11]. When performing traditional BCS for central breast tumors, NAC and the tumor are excised en bloc, and the defect is closed using either a wedge excision or a purse-string suture. However, many women are dissatisfied with the cosmetic results [12, 13]. In 1993, Galimberti et al. reported an oncoplastic procedure involving a Grisotti flap for the management of centrally located breast cancer. They described the technique as an excision of NAC directly over the site of the tumor, extending down to mobilize a dermoglandular flap, which is then de-epithelialized to reshape the breast cancer and recreate the areola [14]. We introduced displacement using Grisotti’s flap for centrally located breast cancer in Japanese patients and found that this simple technique generated excellent results [15]. Until this study, we considered that the indications for volume displacement using Grisotti’s flap were limited to patients with middle-sized or large and/or ptotic breasts, and the skin was soft. However, we reported several experiences of OPBSC for patients with small- to middle-sized breasts; the volume replacement technique with extra-mammary tissue was adequate to fill the defect and thereby obtain symmetrical results [16,17,18,19,20]

Based on these experiences, Grisotti’s flap may be useful for the repair of central breast defects in patients with relatively large breasts. We considered that there was a limitation of Grisotti’s technique for patients without large breasts; a higher excision ratio to the breast leads to worsening cosmetic results, especially in patients with small-to medium-sized breasts. Conversely, we noticed that volume displacement using Grisotti’s flap was an excellent technique for repairing central breast defects. In addition, we encountered two patients requiring OPBCS. One involved modifying V-mammoplasty for a cancer lesion in the inner lower area of a large breast in the same way as for a patient with a non-ptotic small breast [21]. The other involves creating a new IML and elevating the tissue below the true inframammary area to form part of a new breast mound [22]. Based on this experience, in the present case, we modified the original flap by adding skin and fatty tissue to the extra-breast area in a similar manner. If we performed Grisotti’s technique in this patient without a non-ptotic, middle-sized breast, the size of the operated breast would be smaller than that of the contralateral breast due to loss of the skin and breast tissue. The IML of the treated breast must have been moved to the cranial side. It is also predicted that it would be difficult to reproduce the angle of the inframammary area, which we achieved by using the modified Grisotti’s flap, volume displacement, volume replacement, and reproducing the IML.

In this study, the Japanese patient had a medium-sized and non-ptotic breast. We planned to resect the central area of the breast with the nipple–areola complex and reconstruct the breast mound using the modified Grisotti flap. We resected 29 g of tissue; the total operating period was 89 min, and reconstruction took 53 min. No complications were noted either during or after the surgery. Partial defects were repaired using skin fatty tissue in the lateral area of the breast. We also repaired a central circular defect of the areola. The remaining breast volume in the inner to lower area of the breast was increased to equate with the original breast tissue using caudal skin fatty tissue.

This resulted in an adequate volume to fill the defect and make the breast symmetrical. Therefore, it is important to avoid drawing a new IML that is extremely low. The appropriate distance between the new and original inframammary fold lines is unclear. However, based on our past experiences, a distance of approximately 15–20 mm may be reasonable for patients without breast ptosis and relatively small breasts, for whom this technique may be useful.

In this study, the inner line of the J-shaped area was cut from the surface of the dermis to the bottom of breast tissue (Fig. 2e). Cutting the outer line instead and attaching Grisotti's flap caudally might allow the flap, along with the inframammary fold tissue, to be more efficiently moved cranially. Further modifications such as this would make Grisotti’s technique more useful, although it involves a significant alteration of the procedure.

A contraindication for this technique is the use of a large areola for a relatively small or fatty breast, similar to Grisotti’s methods.

When repairing a central breast defect using Grisotti’s flap or a modified Grisotti’s flap in patients with ptotic breasts, it may be difficult to maintain symmetry because of the size of the original breasts.