Ptosis (breasts)

Ptosis (breasts)
Classification and external resources
ICD-9-CM	611.81
eMedicine	plastic/128

Female breast ptosis or sagging is a natural consequence of aging. The rate at which a woman's breasts droop and the degree of ptosis depends on many factors. The key factors influencing breast ptosis over a woman's lifetime are cigarette smoking, her number of pregnancies, gravity, higher body mass index, larger bra cup size, and significant weight gain and loss.^[1] Post-menopausal women may experience increased ptosis due to a loss of skin elasticity. Many women and medical professionals mistakenly believe that breastfeeding increases sagging. It is also commonly believed that the breast itself offers insufficient support and that wearing a bra prevents sagging which has not been found to be true.^[2]

Plastic surgeons categorize the severity of ptosis by evaluating the position of the nipple relative to the infra-mammary fold, the point at which the underside of the breasts attach to the chest wall. In the most advanced stage, the nipples are below the fold and point towards the ground.

Breast structure

Anatomically, a female's breasts do not contain any muscle but are composed of soft, glandular tissue. Breasts are composed of mammary glands, milk ducts, adipose tissue (fat tissue) and Cooper's ligaments.

Mammary glands remain relatively constant throughout life. Fat tissue surrounds the mammary glands, and its volume will normally vary throughout life. Although the exact mechanisms that determine breast shape and size are largely unknown,^[3] the amount and distribution of fat tissue and, to a lesser extent, mammary tissue, cause variations in breast size, shape and volume. The Cooper's ligaments offer minimal connective tissue to support the breasts.

Causes

University of Kentucky plastic surgeon Brian Rinker encountered many women in his practice who attributed their sagging breasts to breastfeeding, which was also the usual belief among medical practitioners.^[4] He decided to find out if this was true, and between 1998 and 2006 he and other researchers interviewed 132 women who were seeking breast augmentation or breast lifts. They studied the women's medical history, body mass index (BMI), their number of pregnancies, their breast cup size before pregnancy, and smoking status. The study results were presented at a conference of the American Society of Plastic Surgeons.^[1]

Key factors

According to Rinker's research, there are several key factors. A history of cigarette smoking "breaks down a protein in the skin called elastin, which gives youthful skin its elastic appearance and supports the breast." The number of pregnancies was strongly correlated with ptosis, with the effects increasing with each pregnancy.^[1] As most women age, breasts naturally yield to gravity and tend to sag and fold over the inframammary crease, the lower attachment point to the chest wall. This is more true for larger-breasted women. The fourth reason was significant weight gain or loss (greater than 50 pounds (23 kg)).^[1] Other significant factors were higher body mass index and larger bra cup size.^[5]

Breastfeeding not a factor

In Rinker's study, 55% of respondents reported an adverse change in breast shape after pregnancy. Many women mistakenly attribute the changes and their sagging breasts to breastfeeding,^[6] and as a result some are reluctant to nurse their infants. Research shows that breastfeeding is not the factor that many thought it was.^[1] Rinker concluded that "Expectant mothers should be reassured that breastfeeding does not appear to have an adverse effect upon breast appearance."^[1] Also discounted as causes affecting ptosis are weight gain during pregnancy and lack of participation in regular upper body exercise.^[5]

Effect of vigorous exercise

When running, breasts may move three dimensionally: vertically, horizontally and laterally, in an overall figure-8 motion. Unrestrained movement of large breasts may contribute to sagging over time.^[7] Motion studies have revealed that when a woman runs, more than 50% of the breast's total movement is vertical, 22% is side-to-side, and 27% is in-and-out.^[8] A 2007 study found that encapsulation-type sports bras, in which each cup is separately molded, are more effective than compression-type bras, which press the breasts close to the body, at reducing total breast motion during exercise. Encapsulation bras reduce motion in two of the three planes, while compression bras reduce motion in only one plane.^[9] Previously, it was commonly believed that a woman with small to medium-size breasts benefited most from a compression-type sports bra, and women with larger breasts need an encapsulation-type sports bra.^[8]

Presentation

A woman's breasts change in size, volume, and position on her chest throughout her life. In young women with large breasts, sagging may occur early in life due to the effects of gravity. It may be primarily caused by the volume and weight of the breasts which are disproportionate to her body size.^[1]

Impact of pregnancy

During pregnancy, the ovaries and the placenta produce estrogen and progesterone. These hormones stimulate the 15 to 20 lobes of the milk-secreting glands in the breasts to develop. Women who experience multiple pregnancies repeatedly stretch the skin envelope during engorgement while lactating. As a woman's breasts change in size during repeated pregnancies, the size of her breasts change as her mammary glands are engorged with milk and as she gains and loses weight with each pregnancy.^[7] In addition, when milk production stops (usually as a child is weaned), the voluminous mammary glands diminish in volume, but they still add bulk and firmness to the breast. These changes in the mammary glands contribute further to sagging.

Middle-aged women

In middle-aged women, breast ptosis is caused by a combination of factors. If a woman has been pregnant, postpartum hormonal changes will cause her depleted milk glands to atrophy. Breast tissue and suspensory ligaments may also be stretched if the woman is overweight or loses and gains weight. When these factors are at play, the breast prolapses, or falls forward. When a woman with sagging breasts stands, the underside or inferior skin of the breast folds over the infra-mammary fold and lies against the chest wall. The nipple-areola complex tends to move lower on the breast relative to the inframammary crease. The nipple of the breast may also tend to point downward.

Post-menopausal women

In post-menopausal women, breast atrophy is aggravated by the inelasticity of over-stretched, aged skin.^[10] This is due in part to the reduction in estrogen, which affects all body tissues, including breast tissue. The loss of estrogen reduces breast size and fullness. Estrogen is also essential to maintaining a fibrous protein called collagen, which makes up much of the breast's connective tissue.

Severe ptosis

Ptosis scale

Stages of ptosis

Plastic surgeons describe the degree of breast sagging using a ptosis scale like the modified Regnault ptosis scale below:^[11][12]

• Grade I: Mild ptosis—The nipple is at the level of the infra-mammary fold and above most of the lower breast tissue.
• Grade II: Moderate ptosis—The nipple is located below the infra-mammary fold but higher than most of the breast tissue hangs.
• Grade III: Advanced ptosis—The nipple is below the inframammary fold and at the level of maximum breast projection.
• Grade IV: Severe ptosis—The nipple is far below the inframammary fold and points toward the floor.
• Pseudoptosis—The nipple is located either at or above the infra-mammary fold, while the lower half of the breast sags below the fold. This is most often seen when a woman stops nursing, as her milk glands atrophy, causing her breast tissue to sag.
• Parenchymal Maldistribution—The lower breast tissue is lacking fullness, the inframammary fold is very high, and the nipple and areola are relatively close to the fold. This is usually a developmental deformity.^[12]

Bras and ptosis

Since breasts are an external organ and do not contain muscle, exercise cannot improve their shape. They are not protected from external forces and are subject to gravity. Many women mistakenly believe that breasts cannot anatomically support themselves and that wearing a brassiere will prevent their breasts from sagging later in life.^[13] Researchers, bra manufacturers, and health professionals cannot find any evidence to support the idea that wearing a bra for any amount of time slows breast ptosis.^[14] Bra manufacturers are careful to claim that bras only affect the shape of breasts while they are being worn.^[13][15]

Bras don't prevent ptosis

Robert Mansell, a professor of surgery at the University Hospital of Wales, in Cardiff, reported that, "Bras don't prevent breasts from sagging, with regard to stretching of the breast ligaments and drooping in later life, that occurs very regularly anyway, and that's a function of the weight, often of heavy breasts, and these women are wearing bras and it doesn't prevent it." John Dixey, at the time CEO of Playtex, agreed with Mansell. "We have no medical evidence that wearing a bra could prevent sagging, because the breast itself is not muscle so keeping it toned up is an impossibility."^[2]

Bralessness improved comfort

Two small studies provide some indication that wearing a bra may have an overall negative effect on sagging breasts. In a Japanese study, 11 women were measured wearing a standardised fitted bra for three months. They found that breasts became larger and lower, with the underbust measurement decreasing and the overbust increasing, while the lowest point of the breast moved downwards and outwards. The effect was more pronounced in larger-breasted women. This may be related to the particular bra chosen for the experiment, as there was some improvement after changing to a different model.^[16]

Medical treatment

Some women with ptosis choose to undergo plastic surgery to make their breasts less ptotic. Plastic surgeons offer several procedures for lifting sagging breasts. Surgery to correct the size, contour, and elevation of sagging breasts is called mastopexy.^[17][18] Women can also choose breast implants, or may undergo both procedures. The breast-lift procedure surgically elevates the parenchymal tissue (breast mass), cuts and re-sizes the skin envelope, and transposes the nipple-areola complex higher upon the breast hemisphere. If sagging is present and the woman opts not to undergo mastopexy, implants are typically placed above the muscle, to fill out the breast skin and tissue. Submuscular placement can result in deformity. In these cases, the implant appears to be high on the chest, while the natural breast tissue hangs down over the implant.

See also

• Pencil test (breasts)

References

Additional sources

• "Soutien-gorge de sport", in Thierry Adam, Gynécologie du sport. Springer 2012, pp 305–309
• "Facteurs de l'évolution morphologique du sein après arrêt du port du soutien-gorge : étude ouverte préliminaire longitudinale chez 50 volontaires. Olivier Roussel; Jean-Denis Rouillon; Université de Franche-Comté. Faculté de médecine et de pharmacie". Thèse d’exercice : Médecine : Besançon : 2009.