Ptosis or sagging of the female breast is a natural consequence of

aging Ageing ( BE) or aging ( AE) is the process of becoming older. The term refers mainly to humans, many other animals, and fungi, whereas for example, bacteria, perennial plants and some simple animals are potentially biologically immortal. In ...

. The rate at which a woman's breasts drop and the degree of ptosis depends on many factors. The key factors influencing breast ptosis over a woman's lifetime are

cigarette A cigarette is a narrow cylinder containing a combustible material, typically tobacco, that is rolled into thin paper for smoking. The cigarette is ignited at one end, causing it to smolder; the resulting smoke is orally inhaled via the opp ...

smoking, her number of pregnancies, higher

body mass index Body mass index (BMI) is a value derived from the mass (weight) and height of a person. The BMI is defined as the body mass divided by the square of the body height, and is expressed in units of kg/m2, resulting from mass in kilograms and he ...

, larger

bra A bra, short for brassiere or brassière (, or ; ), is a form-fitting undergarment that is primarily used to support and cover breasts. It can serve a range of other practical and aesthetic purposes, including enhancing or reducing the appea ...

cup size, and significant weight change. Post-menopausal women or people with collagen deficiencies (such as Ehlers-Danlos) may experience increased ptosis due to a loss of skin elasticity. Many women and medical professionals mistakenly believe that

breastfeeding Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be expressed by hand or pumped and fed to the infant. The World Health Organization (WHO) recommends that br ...

increases sagging. It is also commonly believed that the breast itself offers insufficient support and that wearing a

prevents sagging, which has not been found to be true.

Plastic surgeons Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniofa ...

categorize the degree of ptosis by evaluating the position of the

nipple The nipple is a raised region of tissue on the surface of the breast from which, in females, milk leaves the breast through the lactiferous ducts to feed an infant. The milk can flow through the nipple passively or it can be ejected by smooth mu ...

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 toward the ground.

Signs and symptoms

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

effect Effect may refer to: * A result or change of something ** List of effects ** Cause and effect, an idiom describing causality Pharmacy and pharmacology * Drug effect, a change resulting from the administration of a drug ** Therapeutic effect, a ...

gravity In physics, gravity () is a fundamental interaction which causes mutual attraction between all things with mass or energy. Gravity is, by far, the weakest of the four fundamental interactions, approximately 1038 times weaker than the stro ...

. It may be primarily caused by the volume and weight of the breasts which are disproportionate to her body size.

Impact of pregnancy

During pregnancy, the

ovaries The ovary is an organ in the female reproductive system that produces an ovum. When released, this travels down the fallopian tube into the uterus, where it may become fertilized by a sperm. There is an ovary () found on each side of the body. T ...

and the

placenta The placenta is a temporary embryonic and later fetal organ that begins developing from the blastocyst shortly after implantation. It plays critical roles in facilitating nutrient, gas and waste exchange between the physically separate mater ...

produce

estrogen Estrogen or oestrogen is a category of sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics. There are three major endogenous estrogens that have estrogenic hormonal acti ...

and

progesterone Progesterone (P4) is an endogenous steroid and progestogen sex hormone involved in the menstrual cycle, pregnancy, and embryogenesis of humans and other species. It belongs to a group of steroid hormones called the progestogens and is the m ...

. These hormones stimulate the 15 to 20 lobes of the milk-secreting glands in the breasts to develop. Women who experience

multiple pregnancies A multiple birth is the culmination of one multiple pregnancy, wherein the mother gives birth to two or more babies. A term most applicable to vertebrate species, multiple births occur in most kinds of mammals, with varying frequencies. Such bir ...

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. In addition, when milk production stops (usually as a child is

weaned Weaning is the process of gradually introducing an infant human or another mammal to what will be its adult diet while withdrawing the supply of its mother's milk. The process takes place only in mammals, as only mammals produce milk. The infan ...

), the voluminous mammary glands diminish in volume, but they still add bulk and firmness to the breast. A 2010 review found that weight gain during pregnancy and breastfeeding were not significant risk factors for ptosis.

Middle-aged women

In middle-aged women, breast ptosis is caused by a combination of factors. If a woman has been pregnant, postpartum

hormonal A hormone (from the Greek participle , "setting in motion") is a class of signaling molecules in multicellular organisms that are sent to distant organs by complex biological processes to regulate physiology and behavior. Hormones are required f ...

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

prolapse In medicine, prolapse is a condition in which organs fall down or slip out of place. It is used for organs protruding through the vagina, rectum, or for the misalignment of the valves of the heart. A spinal disc herniation is also sometimes ca ...

s, 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 Menopause, also known as the climacteric, is the time in women's lives when menstrual periods stop permanently, and they are no longer able to bear children. Menopause usually occurs between the age of 47 and 54. Medical professionals often ...

women, breast atrophy is aggravated by the inelasticity of over-stretched, aged skin. This is due in part to the reduction in

, 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.

Ptosis scale

Plastic surgeons describe the degree of breast sagging using a ''ptosis scale'' like the modified ''Regnault ptosis scale'' below: * ''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. * ''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.

Causes

University of Kentucky The University of Kentucky (UK, UKY, or U of K) is a Public University, public Land-grant University, land-grant research university in Lexington, Kentucky. Founded in 1865 by John Bryan Bowman as the Agricultural and Mechanical College of Kentu ...

plastic surgeon Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniof ...

Brian Rinker encountered many women in his practice who attributed their sagging breasts to

, which was also the usual belief among medical practitioners. 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 Breast augmentation and augmentation mammoplasty is a cosmetic surgery technique using breast-implants and fat-graft mammoplasty techniques to increase the size, change the shape, and alter the texture of the breasts. Augmentation mammoplasty is ...

or breast lifts. They studied the women's medical history,

(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. According to Rinker's research, there are several key factors. A history of

smoking "breaks down a protein in the skin called

elastin Elastin is a protein that in humans is encoded by the ''ELN'' gene. Elastin is a key component of the extracellular matrix in gnathostomes (jawed vertebrates). It is highly elastic and present in connective tissue allowing many tissues in the bod ...

, which gives youthful skin its elastic appearance and supports the breast." The number of

pregnancies Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but can ...

was strongly correlated with ptosis, with the effects increasing with each pregnancy. As most women age, breasts naturally yield to

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 ). Other significant factors were higher

and larger

cup size. 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, and as a result some are reluctant to nurse their infants. Research shows that breastfeeding is not the factor that many thought it was. Rinker concluded that "Expectant mothers should be reassured that breastfeeding does not appear to have an adverse effect upon breast appearance." Also discounted as causes affecting ptosis are weight gain during pregnancy and lack of participation in regular upper body exercise.

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. 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. A 2007 study found that encapsulation-type

sports bra A sports bra is a bra that provides support to the breasts during physical exercise. Sturdier than typical bras, they minimize breast movement and alleviate discomfort. Many women wear sports bras to reduce pain and physical discomfort caused ...

s, 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. 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.

Mechanism

Anatomically, a female's

breast The breast is one of two prominences located on the upper ventral region of a primate's torso. Both females and males develop breasts from the same embryological tissues. In females, it serves as the mammary gland, which produces and secret ...

s do not contain any

muscle Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of muscl ...

but are composed of soft, glandular tissue. Breasts are composed of

mammary gland A mammary gland is an exocrine gland in humans and other mammals that produces milk to feed young offspring. Mammals get their name from the Latin word ''mamma'', "breast". The mammary glands are arranged in organs such as the breasts in primat ...

milk duct Lactiferous ducts are ducts that converge and form a branched system connecting the nipple to the lobules of the mammary gland. When lactogenesis occurs, under the influence of hormones, the milk is moved to the nipple by the action of smooth mus ...

adipose tissue Adipose tissue, body fat, or simply fat is a loose connective tissue composed mostly of adipocytes. In addition to adipocytes, adipose tissue contains the stromal vascular fraction (SVF) of cells including preadipocytes, fibroblasts, vascular e ...

(fat tissue) and

Cooper's ligaments Cooper's ligaments (also known as the suspensory ligaments of Cooper and the fibrocollagenous septa) are connective tissue in the breast that help maintain structural integrity. They are named for Astley Cooper, who first described them in 1840. ...

. 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, the amount and distribution of fat tissue and, to a lesser extent, mammary tissue, cause variations in breast size, shape and volume. Some experts believe Cooper's ligaments, which are

connective tissue Connective tissue is one of the four primary types of animal tissue, along with epithelial tissue, muscle tissue, and nervous tissue. It develops from the mesenchyme derived from the mesoderm the middle embryonic germ layer. Connective tiss ...

with the breast, provide some support within breasts, but there's no agreement on whether they provide support or simply divide breast tissue into compartments.

Treatment

Bras

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 A bra, short for brassiere or brassière (, or ; ), is a form-fitting undergarment that is primarily used to support and cover breasts. It can serve a range of other practical and aesthetic purposes, including enhancing or reducing the appear ...

will prevent their breasts from sagging later in life. 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. Bra manufacturers are careful to claim that bras only affect the shape of breasts while they are being worn. In fact, there is some evidence that bra use reduces the development of

, connective tissue that supports breast shape. That atrophy from bra wearing may therefore lead to more breast sag in the long run, much as the connective tissue in a limb weakens while it's in a cast and must be re-strengthened afterward. Studies have actually documented that, after an initial period of adjustment, women experienced a significant increase in comfort and breast firmness from going without bras.

Surgery

Some women with ptosis choose to undergo

plastic surgery Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes cranio ...

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 Mastopexy (Greek μαστός ''mastos'' "breast" + -pēxiā "affix") is the plastic surgery mammoplasty procedure for raising sagging breasts upon the chest of the woman, by changing and modifying the size, contour, and elevation of the breasts. ...

. Women can also choose

breast implants A breast implant is a prosthesis used to change the size, shape, and contour of a person's breast. In reconstructive plastic surgery, breast implants can be placed to restore a natural looking breast following a mastectomy, to correct congenita ...

, 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.