Comparison of Outcome Between Grisotti Flap Versus Reverse Mirror Grisotti Flap for Central Quadrant Breast Tumors
Phase: NA
Conditions: Breast Cancer, Breast Reconstruction
Sponsor: Mayo Hospital Lahore

 
 
Title 
COMPARISON OF OUTCOME BETWEEN GRISOTTI FLAP 
VERSUS REVERSE MIRROR GRISOTTI FLAP FOR 
CENTRAL QUADRANT BREAST TUMORS 
Submitted By: 
Dr. Aqeela Shirazi 
Senior Registrar 
Department of General Surgery, 
Mayo Hospital, Lahore 
 
 
 
 
 
 
 
 
 
 
 
Dated: 
26TH NOVEMBER, 2025 
 
 
 
 

 
 
 
INTRODUCTION:  
Breast cancer amongst women is the most common cancer and the second leading cause 
of deaths related to cancer worldwide.6 Its incidence is rising by 1% annually during 
2012–2021, largely confined to localized-stage and hormone receptor-positive disease.1 
A steeper increase in women < 50 years (1.4% annual) versus >50 years  (0.7%) overall 
was significant only among White women. African/Pacific Islander women had the 
fastest increase in both age groups (2.7% for women <50 years and 2.5% for women > 
50 years per year)1. Hence, young Asian ,American/Pacific Islander women had the 
second lowest rate in 2000 (57.4 per 100,000) but the highest rate in 2021 (86.3 per 
100,000). 1 
In a multitude of developed and emerging countries, including Pakistan, breast cancer is 
a cause of significant morbidity and mortality.1,2 The average age of developing a breast 
cancer among white American women is 61 years, however the average age for 
Pakistani women is 51.4 years.2 
In the past, mastectomy was treatment of choice for any stage of breast cancer.9 
However newer advancements resulting in early diagnosis, providing advancved 
systemic therapies and easy availability of radiotherapy facilities have paved the paths 
for breast conservations.7,9 Sometimes the size and location of the tumor leads to  
undesired aesthetic results which can be encountered when attempting resections with  
safe margins. The major part of the aesthetic problem after breast conservation surgery 
is due to large glandular defects and scars contractures.15 This is where oncoplastic 
techniques are used for the repair of resulting glandular defects without compromising 
the oncological outcomes.7,9,15 
Breast oncoplastic surgery, integrating oncologic and plastic surgery principles, is 
increasingly prevailing in developed as well as developing countries. The technique 
involves precise and thorough planning of incisions,excisions, glandular reshaping and 
nipple areolar complex (NAC) repositioning for improved and symmetrical aesthetic 

 
 
outcomes.3 Oncoplastic breast surgery has hence become the standard of care in breast 
cancer owing to its feasibility,advances and oncological safety .5  
Among the different quadrant tumours, centrally located breast tumours (CLBT) 
account for about 5–20% of all breast cancer cases.7,9 Because of their location CLBT 
pose special oncological and aesthetic concerns. Selecting an optimal surgical approach 
for CLBT remains debated till date, reflecting the complexity of balancing oncologic 
principles with aesthetic outcomes and local control.3 The resection of NAC is almost 
always necessary in central quadrant tumours and aesthetic outcomes  are mostly poor if 
only a standard breast conservative therapy is performed.14 
Oncoplastic approaches for centrally located breast tumours may include Grisotti flap, 
reverse mirror grisotti flap, latissimus dorsi flap, inferior pedicle flap, Melon slice, and 
round block techniques16. For centrally located breast tumours Grisotti flap technique 
has a short learning curve, quick to perform, with a low complication rate, satisfactory 
cosmetic outcome and no loss of body image in the post-operative period making it a 
more physiological procedure.7,13  The oncologic outcome of oncoplastic breast 
conservation was shown to be comparable to the classical mastectomy in cases of 
central breast tumors 10. The Grisotti technique consists of excising central quadrant 
breast tumor alongwith nipple areolar complex and mobilizing a dermo-glandular flap 
which is de-epithelized, rotated and advanced based on inferior and lateral pedicle in 
order to fill the glandular defect and reshape the breast, recreating a neo-areola.8,9  
Grisotti flap is a partial mastectomy and an immediate volume replacement technique10 
The Grisotti flap technique demonstrated superior patient satisfaction alongwith 
aesthetic and psycho-social outcomes while maintaining oncological safety that is 
comparable to that of mastectomy.Hence  Grisotti flap technique is a standard 
alternative to mastectomy, particularly in patients prioritizing aesthetic outcomes. 4,6 
Advances in oncoplastics  have devised the modification of this original technique 
which involves the utilizing other vascular pedicles for the dermoglandular 
advancement and rotation.9  

 
 
A reverse-mirror Grisotti flap, also known as a Reverse-Bay of Bengal modification, is 
a variation of the Grisotti flap technique used in breast cancer surgery. It is designed to 
reconstruct defects in the central breast quadrant  after a breast conservation surgery. 
This modification involves re-orienting the flap medially where it is dependent mainly  
on the perforators of internal mammary artery for blood supply, potentially offering 
better aesthetic results and more versatile and robust blood supply. The Grisotti flap, 
despite its well known utility, has limitations, particularly in patients with non-ptotic 
breasts, where it may lead to fullness laterally and suboptimal cosmesis, the Reverse 
Bay of Bengal modification of the Grisotti flap is designed to address these limitations 
by preserving chest wall perforators and avoiding excessive lateral buldging.11 This 
technique hence offers a more cosmetic alternative for patients with central quadrant 
tumors requiring nipple-areola complex (NAC) excision.11 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
OBJECTIVES:  
To compare the outcome between grisotti flap versus reverse mirror grisotti flap in terms 
of flap viability, cosmetic outcome (visual analogue scale) and seroma formation. 
 
 

 
 
 
OPERATIONAL DEFINITIONS:  
1. Centrally located breast tumors (CLBT): 
Tumors that are completely or partially located in the projection of the areola up to the 
chest wall and/or within 2 cm around the areola 
 
2. Grisotti Flap:  
The  Grisotti flap is a local rotational flap used to reconstruct defects after removing a 
central breast cancer, often involving the nipple-areola complex (NAC). It uses tissue 
from the inferior pole of the breast to fill the central defect.  
 
3. Reverse-Mirror Flap:  
 
The reverse-mirror version is a modification where the flap is flipped and reoriented, 
using the internal mammary vessels as the primary blood supply.  
 
4. Flap viability:  
Absence of necrosis of new areola formed as seen clinically at 48 hours and 7th day 
postoperatively.  
Flap viability categories: 
A (None): No necrosis. 
B (Color Change): Color change suggesting impaired perfusion or ischemic 
injury.  
C (Partial Thickness): Partial thickness skin flap necrosis resulting in wound 
breakdown. 
 
D (Full Thickness): Full thickness skin flap necrosis. 
 
5. Cosmetic outcome: 
Cosmetic outcome will be explained with VAS (visual analogue scale) by 
the patient. The scale will range from 0-10 with 0 being categorized as 
worst cosmetic outcome and 10 being categorized as best cosmetic 
outcome. 

 
 
 
 
6. Seroma formation: 
Seroma formation is the visible swelling at  the operative site which will be 
confirmed and quantified by ultrasound on 7th post operative day with 
volume more than 20ml. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
HYPOTHESIS:  
There is a difference in the outcome between Grisotti versus Reverse Mirror Grisotti flap 
in centrally located breast cancers. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
MATERIAL AND METHODS:  
STUDY DESIGN: Randomised Control Trial 
SETTING: SURGICAL FLOOR, MAYO HOSPITAL LAHORE. 
DURATION OF STUDY: 06 months after approval of synopsis. 
SAMPLE SIZE:  Sample size of 106 patients (53 patients in each group) is 
estimated by using 95% confidence level, 10% absolute precision with expected 
percentage satisfaction rate in group A as 90% and in group B as 95%. 
                n =  Z21- α/2 (P1(1-P1) + P2(1-P2) 
 
 
            d2 
Z1- α/2 = confidence level 95% = 1.96 
P1 = population proportion A= 90% 14 
P2 = Population proportion B = 95% 8 
d = absolute precision 10 % 
SAMPLING TECHNIQUE: computer generated random table. 
SAMPLE SELECTION:  
 
Inclusion Criteria: 
1. Diagnosed cases of breast cancer patients 
2. Gender: Females 
3. Age: 25-70 years 
4. T1 (<2cm) and T2 (2-5cm)  tumors with or without prior systemic 
therapy 
5. Tumor located in the NAC or located within 2 cm of the edge of the 
areola 
 
Exclusion Criteria: 
1. Metastatic breast cancer 
2. Inflammatory breast cancer 
3. Patients not willing for post-operative radiotherapy 
4. High tumour-breast ratio 
DATA COLLECTION PROCEDURE:  

 
 
The study approval will be taken from the Ethical Committee of the King Edward 
Medical University, Lahore and will be performed in accordance with the current revision 
of the Helsinki Declaration. Informed consent will be obtained from all individual 
participants with diagnosis of central quadrant breast tumors as per operational definition, 
and data will be collected on predesigned proforma. Patients will be divided into two 
groups, Grisotti flap (group A) and Reverse Mirror Grisotti Flap (group B). Patients will 
be recruited from OPD of Mayo hospital during the same study period. 
 
Patients fulfilling the inclusion criteria will be randomly divided into either group. 
Pre-operative marking will be done in standing position. All procedures will be done 
under general anesthesia. Circumareolar incision will be given for excision of tumor 
alongwith nipple areolar complex. New areola will be marked beneath the previous nipple 
areolar complex and de-epithelialisation of infra-neo-areolar skin will be done . In group 
A, the dermoglandular flap will be raised on infero-lateral perforators of intercostal 
arteries and will be rotated and advanced to fill the gap . In group B, the dermoglandular 
flap will be raised on the medial perforators of internal mammary artery and will be 
rotated and advanced to fill the defect. In both groups, glandular approximation will be 
done with vicryl 3-0 interrupted sutures and skin will be closed with prolene 4-0 
subcuticular sutures. Axillary lymph node dissection or sentinel lymph node biopsy will 
be done as indicated in each patient. 
 
Post operatively flap viability will be assessed at 48 hours  and on 7th day. Cosmetic 
outcome will be assessed using visual analogue scale on 7th  postoperative day. Seroma 
formation will be assessed on 7th day post-operatively. 
 
 
 
 
 
DATA ANALYSIS PRODECURE:  

 
 
All the collected data will be entered and analyzed by using Statistical Package for the 
Social Sciences (SPSS,25). Quantitative data (cosmetic outcome with VAS) will be 
expressed as mean (M) ± S.D. Independent T test will be used for comparing means for 
cosmetic outcome. Qualitative data (tumor size, flap viability and seroma formation) 
will be expressed as frequencies and percentages. Chi square (X2) test will be used to 
compare between groups for qualitative data. The association between type of 
procedure used and clinical outcome variable will be assessed by using Odds Ratio 
(OR) with  95% confidence interval (CI). The P value will be considered significant if it 
is less than 0.05. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
OUTCOME & UTILIZATION:  

 
 
Breast conservation surgery is equivalent to mastectomy for early stage breast cancer 
patients. Central quadrant tumours can be treated with various oncoplastic techniques 
with a satisfactory aesthetic outcome and low morbidity. Grisotti flap and reverse mirror 
grisotti flap are the favourable viable surgical options for central quadrant breast tumours. 

 
 
 
REFERENCES: 
1. Giaquinto AN, Sung H, Newman LA, Freedman RA, Smith RA, Star J., et al. 
Breast cancer statistics 2024. CA: a cancer journal for clinicians. 2024 ;74(6):477-
95. 
2. Siddiqui, Ruqaiyyah, Malik Hassan Mehmood, Naveed Ahmed Khan. "An 
overview of breast cancer in Pakistan." Discover Medicine 1.1 (2024): 82. 
3. Koppiker CB, Noor AU, Joshi S, Mishra R, Sivadasan P, Sheikh S., et 
al.Pushing the Boundaries for Centrally Located Breast Tumors in 
Oncoplastic Breast Surgery: A Single Centre Audit. medRxiv. 2024 ; 
25:2024-11. 
4. Ozgul H, Celik O, Sakar B, Celik A, Oener OZ. Postoperative patient 
satisfaction and oncological Outcomes of Grisotti flap vs. Total 
mastectomy: A retrospective analysis 
5. Abdelkader AA, El-Fayoumi T, Roushdy A, Asal MF. Comparison 
between conventional and oncoplastic breast surgeries regarding resection 
margins and local recurrences in breast cancer: Retrospective study. The 
Egyptian Journal of Surgery. 2023; 7;42(4). 
6. Bhattacharya A, Maitra D. A comparative study of surgical, oncological and 
aesthetic outcomes in conventional breast-conserving versus oncoplastic breast-
conserving surgery for excision of breast tumour. European Journal of Cancer. 2024 
;1;200. 
7. Sharma S, Pao K. Grisotti flap for central quadrant breast tumours: quick, 
cosmetic and easy to learn–a case series. Visualized Cancer Medicine. 
2025;6:2. 
8. Dabiri C, Hotton J, Wehbe K, Gornes H, Garbar C, Guillemin F., et al. 
Assessment of the Grisotti oncoplastic procedure for the management of 
central breast tumors. The Breast Journal. 2021 ;27(7):595-602. 

 
 
9. Chen Y, Chen Q, Dong J, Liu D, Huang L, Xie F., et al. Modified Grisotti 
flap technique in centrally located breast cancer: case report. Gland 
Surgery. 2021 ;10(9):2867. 
10. El Dahshasn ME, Khalil HM, Elnemr AA. The outcome of Grisotti flap 
oncoplastic technique in central breast cancer: case series. International 
Surgery Journal. 2023 ;10(5):912-7. 
11. Das S, Mallick AA, Agarwal R, Sarkar DK. “Reverse Bay of Bengal” 
Modification of Grisotti Flap for Reconstruction of Central Quadrant 
Tumors. Indian Journal of Surgical Oncology. 2025 28:1-4. 
12. Deabes SM, Abdelatty WR, Salah RE. Oncoplastic Surgical Techniques in 
Treatment of Central Breast Cancer. Al-Azhar International Medical 
Journal. 2024;5(4):58. 
13. Essa MS, Ahmad KS, Salama AM, Zayed ME. Cosmetic and oncological outcome 
of different oncoplastic techniques in female patients with early central breast 
cancer. International Journal of Surgery Open. 2021 ;32:100336. 
14. Farouk O, Attia E, Roshdy S, Khater A, Senbe A, Fathi A., et al. The outcome of 
oncoplastic techniques in defect reconstruction after resection of central breast 
tumors. World journal of surgical oncology. 2015 ;13(1):285. 
15. Emiroğlu M, Sert İ, İnal A. The role of oncoplastic breast surgery in breast cancer 
treatment. The journal of breast health. 2015 ;11(1):1. 
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Institute. 2014 ;26(4):203-9. 
 
 
 
 
 
 

 
 
  Data Collection Proforma 
 
Sr. #:________Name: _______________Age: ________  Gender: _____ 
 
 
  
Marital status: ________                      Education status: ___________  
 
 
Residence: ______________________________                 Contact #: __________ ,
 
 
History of smoking: yes/no, 
 
      family history of any cancer: 
yes/no___________ 
1st degree: _____2nd degree:__________ 
    3rd 
degree:_____________, Caste:________, children:_________   Breast fed: yes/no,  
 
 
 
 
Age of menarche:_______, 
 
H/O contraceptive use:________  
Consanguineous marriage: yes/no_____ 
Menopause: yes/no                   
H/O alcohol use: yes/no, H/O smoking: 
________ 
Chronic liver disease: yes/no              Chronic renal failure: yes/no 
Tuberculosis: yes/no 
 
 
Inflammatory bowel disease: yes/no        
Autoimmune disease: yes/no 
 
Previously treated any cancer disease: yes/no 
Breast cancer with pregnancy: yes/no    
Diagnosis (histopathology) ____________,  
Histological grade: I____________, II___________, III____________ 
Receptors: ER______PR________Her 2 neu____________others___________ 
Stage_____________     Chemo status______________________ 
Surgery type______________________Radiotherapy_______________ 
 
 
Variable 
Group A (grisotti flap) 
Group B (reverse mirror 
grisotti flap) 
Flap viability 
(A-D) 
At 48 
hours 
On 7th 
post-op 
day 
At 48 
hours 
On 
7th 
post-op 
day 
 
 
 
 
Cosmetic 
outcome  
(visual 
analogue 
scale) 
 
 
Seroma 
formation  
On 7th post-
op day 
Yes / No 
Yes / No 
 
 
 
 

 
 
Informed Consent Form 
COMPARISON OF OUTCOME BETWEEN GRISOTTI FLAP VERSUS REVERSE MIRROR 
GRISOTTI FLAP FOR CENTRAL QUADRANT BREAST TUMORS. 
The doctor has explained me about my disease. The research modalities required for treating my tumour 
have been thoroughly explained to me. As this research work requires the utilization of either grisotti or 
reverse mirror grisotti flap technique, therefore  I allow the doctor to utilize any of these procedures on 
me. 
I also have been informed in detail about the possible benefits and side effects of the study. I understand 
that I am free to withdraw from the study whenever I want to, and I have been informed that my doctors 
will continue to give me all possible care even after my discontinuation form the study. 
Furthermore, I allow my doctor or any other person authorized by my doctor to contact me at my home 
or at any an address given by me whenever required. I have been assured that the information provided 
by me will be kept confidential and will be used for research purpose only. 
Patient name:_____________ 
NIC #:__________________ 
Signature/thumb impression:__________ 
Investigator signature:____________