Ptosis

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

Ptosis of the breast is the medical term for what in popular culture is referred to as drooping or sagging female breasts. Many women and medical professionals mistakenly believed that the breast itself offered insufficient support and that wearing a bra prevented sagging. Many also believed that nursing increased sagging.

Ptosis is a natural consequence of aging. The rate at which a woman develops and the degree of ptosis depends on many factors. The exact cause of ptosis was unknown until 2006 when a study identified specific factors. This research found that the primary influencing factors over a woman's lifetime on sagging are cigarette smoking, a woman's body mass index (BMI), her number of pregnancies, and her breast size before pregnancy. Breast ptosis is influenced by heredity, which determines a woman's skin elasticity, breast size, and the balance of adipose and glandular tissue. Weight gain and the consequential increase in breast size and skin elasticity contribute to ptosis.

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, breasts do not contain any muscle but are composed of soft, glandular tissue. Breasts are composed of the mammary glands, which remain relatively constant throughout life, milk ducts, adipose tissue, or fat tissue, that surrounds the mammary glands, and Cooper's ligaments, which offer minimal connective tissue to support the breasts.

The volume of fat tissue can vary throughout life. Although the exact mechanisms that determine breast shape and size are largely unknown,^[1] the amount and distribution of adipose tissue and, to a lesser extent, mammary tissue, cause variations in breast size, shape, and volume.^[2]

Causes

Sagging is partly determined by inherited traits like skin elasticity and breast density, which affects the ratio of lightweight fat to heavier mammary glands.^[2] Some of the sagging is due to the aging of the glandular tissues that produce breast firmness.^[2] The biggest factors affecting ptosis are cigarette smoking, a woman's body mass index (BMI), her number of pregnancies, her breast cup size before pregnancy, and age.^[3][4]

Key factors

University of Kentucky plastic surgeon Brian Rinker encountered many women in his practice who attributed their sagging breasts to breastfeeding, which was the usual belief among medical practitioners.^[2][5] 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^[3][6]

According to Rinker's research, there are four key factors. Cigarette smoking "breaks down a protein in the skin called elastin, which gives youthful skin its elastic appearance and supports the breast." Pregnancy was strongly correlated to ptosis, with the effects increasing with each pregnancy."^[6] 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 weight gain and loss.^[3]

Breastfeeding not a factor

Many women mistakenly think that breastfeeding causes their breasts to droop,^[7] and as a result some are reluctant to nurse their infants. Research shows that breastfeeding is not the factor that many thought it was.^[8]

Effect of vigorous exercise

Large breasted women who engage in vigorous exercise and don't wear a correctly sized sports bra can stretch breast connective tissue. When running, for example, breasts move three dimensionally: vertically, horizontally, and laterally, in an overall figure-8 motion. Unrestrained movement of large breasts may contribute to sagging over time.^[9] 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.^[10] 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.^[11] 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.^[10]

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. 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. As women age, the suspensory ligaments that help support the mammary glands are naturally stretched and gradually lose strength.

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.^[9] 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.^[2] 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, whether or not she has breastfed her children, 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 woman, breast atrophy is aggravated by the inelasticity of over-stretched, aged skin.^[12] 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.^[2]

Ptosis scale

Stages of ptosis

Plastic surgeons express the degree of breast sagging using a ptosis scale like the modified Regnault ptosis scale below:^[13][14]

• 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 point 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 inframmary fold is very high, and the nipple and areola are relatively close to the fold. This is usually a developmental deformity.^[14]

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 because breasts cannot anatomically support themselves that wearing a brassiere will prevent their breasts from sagging later in life.^[15] Researches, 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.^[16] Bra manufacturers are careful to claim that bras only affect the shape of breasts while they are being worn.^[15][17]

Bras don't prevent sagging

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."^[18]

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."^[19][20]

Franklin interviewed Dr. Christine Haycock a surgeon at the New Jersey Medical School and an expert in sports medicine.^[21] 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.^[20]

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."^[20]

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.^[22]

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.^[23][24]

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.^[25][26] 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.

References