Ptosis (breasts)

For other uses, see Ptosis.

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

Stages of ptosis

Ptosis of the breast refers to drooping or sagging of the female breast. Ptosis is a natural consequence of aging, though the rate at which a woman develops ptosis depends on many factors. As women mature, their breasts usually fold over the infra-mammary fold, the crease where the underside of the breasts attach to the chest wall. When a woman with sagging breasts stands, the breast's lower (inferior) surface lies against the chest wall. In popular culture, this maturation is referred to as "sagging" or "drooping", although plastic surgeons refer to it as ptosis.

Breast ptosis is caused by genetics, but smoking, a woman's body mass index (BMI), her number of pregnancies, her breast size before pregnancy, and age are all influencing factors. Ptosis is not a result of nursing, though it is influenced by the number of pregnancies. Ptosis can occur after weight gain and subsequent loss. Increased breast size makes ptosis more likely. Plastic surgeons categorize ptosis by evaluating the position of the nipple relative to the inframammary crease.

Breast structure

Anatomically, the breasts are composed of soft, glandular tissue, with few support structures, such as connective tissue. Breasts are composed of the mammary glands, which remain relatively constant throughout life, as well as the adipose tissue or fat tissue that surrounds the mammary glands. Although the exact mechanisms that determine breast shape and size are largely unknown, the amount and distribution of adipose tissue and, to a lesser extent, glandular tissue cause variations in breast size.

Etiology

Sagging is partly determined by inherited traits, but cigarette smoking, a woman's body mass index (BMI), her number of pregnancies, her breast size before pregnancy, and age are all influencing factors.

As most women grow older, their breasts naturally tend to sag and fold over the inframammary crease, the lower attachment point to the chest wall. When women stand, the lower (inferior) surface of the sagging breast lies against the chest wall. The nipple of the breast may also tend to point downward. In popular culture, this normal process is referred to as "sagging" or "drooping", while plastic surgeons refer to it medically as ptosis.

Pathophysiology and presentation

A woman's breasts change in size, volume, and position on her chest throughout her life. In young woman with large breasts, sagging may occur early in life. It may be primarily caused by the volume and weight of the breasts which are disproportionate to her body size. The elasticity of each of her thin, young breast's skin envelope can also contribute to sagging.

In middle-aged women, breast ptosis is caused by a combination of factors. If she has had children, postpartum hormonal changes will cause the depleted milk glands to atrophy. Women who experience multiple pregnancies repeatedly stretch the skin envelope during engorgement while lactating. In addition, after the birth of each child, the voluminous milk glands diminish in size, contributing further to sagging. As a woman's breasts grow in size during repeated pregnancies, the suspensory ligaments that maintain the position of the mammary glands against the chest, are stretched and gradually lose strength.

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 standing, the underside or inferior skin of the breast folds over infra-mammary fold surface and lies against the chest wall. The nipple-areola complex tends to move lower on the breast relative to the inframammary crease.

In post-menopausal woman, breast atrophy is aggravated by the inelasticity of over-stretched, aged skin.

The degree of mammary gland prolapse (breast ptosis) is determined with the modified Regnault ptosis grade scale:

• Pseudoptosis — The nipple is located either at or above the infra-mammary fold, while the lower half of the breast sags . A woman may experience false ptosis when, as she stops nursing, her milk supply diminishes and her milk glands atrophy in size.

• Grade I: Mild ptosis — The nipple is located below the infra-mammary fold, but remains located above most of the lower breast tissue.

• Grade II: Moderate ptosis — The nipple is located below the infra-mammary fold but some breast tissue hangs lower than the nipple.

• Grade III: Severe ptosis — The nipple is far below the inframammary fold and hangs lower than the surrounding breast tissue.

Bras and ptosis

Many women mistakenly believe that wearing a brassiere will prevent their breasts from sagging later in life and that breasts cannot anatomically support themselves.

Bras don't prevent sagging

There are conflicting opinions but no known studies to show that bras actually delay the natural process of sagging. Health professionals have, however, found no evidence to suggest that wearing a bra for any amount of time slows ptosis of breasts. Bra manufacturers will only claim that bras only affect the shape of breasts while they are being worn. A bra only provides support to women's breasts while they are wearing the bra.

Deborah Franklin, a senior writer in science and medicine, wrote in Health magazine that, "Still, the myth that daily, lifelong bra wearing is crucial to preserving curves persists, along with other misguided notions about that fetching bit of binding left over from the days when a wasp waist defined the contours of a woman’s power."

Franklin interviewed Dr. Christine Haycock a surgeon at the New Jersey Medical School and an expert in sports medicine. Dr. Haycock said that "Cooper's ligaments have nothing to do with supporting breast tissue... They just serve to divide the breast into compartments." She noted that most women's breasts begin to droop with age and that extremely large-breasted women are generally more affected. However, sagging is not related to ligaments or dependent on breast size.

Pare away the fiction and fears, and the pros and cons of the bra come down to this: If a woman chooses to wear one because it makes her feel good-more supported, more under control or just prettier-more power to her... Haycock suggests that women let pain be their guide when deciding whether to wear a bra during exercise, and when choosing a particular style.

Large-breasted women may be uncomfortable exercising without a bra, but Dr. Haycock said that “It’s not doing any lasting damage to chest muscles or breast tissue.” Her research found that “those who wore an A cup were frequently most comfortable with no bra at all."

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.

These findings were confirmed in a much larger French study of 250 women who exercised regularly and were followed by questionnaires and biometric measurements for a year after agreeing not to wear a bra. While there was some initial discomfort at the first evaluation, this gradually disappeared and by the end of the year nearly all the women had improved comfort compared to before the study. The measurements showed firmer, and more elevated and youthful breasts. One example is given of a woman who had breasts that were uncomfortably large, and who had improvement after two years of being without a bra.

Medical treatment

Main article: Mastopexy

Health ethicists are concerned that plastic surgery and implants have altered our concept of what is "normal" and medicalised women's bodies by making the normal aging process a "disease."

Some women with ptosis choose to undergo plastic surgery to make their breasts less ptotic. Plastic surgeons offer several procedures for lifting breasts that have sagged. Surgery to correct the size, contour, and elevation of sagging breasts is called mastopexy. 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.