Why do breasts sag?

1. What is breast ptosis?

It is the medical term for sagging breasts: the gland descends within a stretched envelope of skin, and the upper part of the breast empties. Its grade is measured by the position of the nipple in relation to the fold beneath the breast.

Grade	Position of the nipple	Usual treatment
Pseudoptosis	Well positioned, above the fold; it is volume that is lacking	Augmentation with implants or lipofilling
Minor ptosis	Level with the fold	Mastopexy around the areola, or implants alone if volume is lacking
Moderate ptosis	Below the fold, pointing downwards	Mastopexy
Major ptosis	Well below the fold, pointing downwards	Mastopexy, inverted-T scar

2. How is the breast held in place?

The skin is the breast’s main support. It is connected to the gland by fibrous partitions, Cooper’s ligaments, over the whole front of the breast except at the nipple. The breast is also held by its boundaries: the fold beneath the breast, especially its inner part, the upper part of the breast, and its inner and outer edges.

The areola and nipple are the keystone of the whole structure: all the partitions and ducts of the gland converge towards them, and this is where the skin adheres most closely to the gland. When the skin loses its elasticity or the gland loses volume, these attachments give way and the breast descends.

3. Breasts that sag from a young age (constitutional ptosis)

• Simple morphological ptosis is the most common form. It often runs in families, with no cause found.
• Weak skin: the gland sits low in an envelope that is empty at the top, the skin has stretch marks without any change in weight, and brothers or sisters often have spontaneous stretch marks. This is the case in Ehlers-Danlos syndrome and other conditions with weak skin elasticity, which become apparent at puberty. After correction, ptosis recurs more often.
• An excess of cortisol (hypercortisolism) also weakens the skin’s elasticity.
• A malformation of the gland, such as tuberous breasts, whose lower part has developed little.

4. Breasts that sag over time (acquired ptosis)

Acquired ptosis most often combines two phenomena, after pregnancy, breastfeeding or weight loss, or with age:

• loss of volume: the gland shrinks or is replaced by fat, and the deflated breast appears to sag (pseudoptosis);
• deterioration of the skin: it becomes thinner, develops stretch marks and comes away from the gland; under the weight of the breast, it stretches.

5. How does the skin of the breast age?

Like the face, the breasts age. The skin gradually loses what makes it firm and elastic:

• collagen gradually decreases with age, as do the cells that produce it (fibroblasts);
• the most superficial elastic fibres disappear from about the age of 30, the deeper ones later;
• skin thickness only decreases after about the age of 60.

Changes in volume and hormones (puberty, menstrual cycles, pregnancy, breastfeeding, weight gain or loss) also damage the thickness and elasticity of the skin. The menopause speeds up this ageing: oestrogens, which stimulate the production of collagen and hyaluronic acid, fall sharply; the skin becomes thinner and looser, which encourages ptosis. Smoking damages the elastic fibres and the skin’s microcirculation, which can speed up its ageing.

6. What about stretch marks?

A stretch mark is a scar within the thickness of the skin. It appears when the skin is put under tension (puberty, pregnancy, breastfeeding, weight gain) or when the body produces too many corticosteroids (stress, Cushing’s disease, corticosteroid treatment): the cells that produce collagen are blocked, and the fibres break. Red and inflamed at first, the stretch mark becomes a fine white scar, perpendicular to the direction of tension.

On the breast, their appearance tells us about the skin:

• stretch marks radiating over the whole breast indicate a permanent loss of the elastic fibres of the entire envelope;
• fine stretch marks, limited to the base of the breast and mainly due to gravity, are less unfavourable: the skin has retained some of its elasticity.

7. Which breasts hold up best?

Some breasts resist gravity better. The factors of stability are:

• moderate volume;
• a wide base;
• a distance of about 5 cm between the areola and the fold;
• short projection;
• a rounded chest wall.

Without them, the breast puts more strain on its attachments and tends to sag.

8. Why skin quality matters before a procedure

At the consultation, the skin is assessed by looking, by touch, by pinching it and by lifting the gland by hand. It partly determines the technique and how well the result will hold.

Skin	What is observed	Consequence
Good	Thick, toned and elastic skin, sufficient layer of fat, well attached to the gland	It redrapes well and holds the result; if very firm over a small breast, it limits the volume of an implant
Average	Slightly loose skin, a few stretch marks, average attachment to the gland	All intermediate situations
Poor	Thin, stretched, crêpey skin, radiating stretch marks, little fat, gland that slides beneath the skin	An implant alone stretches the skin further: the breast may slide over the implant and the ptosis recur; a lift is combined

9. Can sagging breasts be prevented?

Ageing cannot be prevented, but what speeds it up can be limited: keeping a stable weight, stopping smoking, protecting the cleavage from the sun. No cream or exercise lifts a breast that has already sagged: the pectoral muscle lies beneath the gland and does not support it.

10. How can sagging breasts be corrected?

The treatment for ptosis is mastopexy, or breast lift. It removes the excess skin and reshapes the gland; its scars depend on the grade of ptosis.

Situation	Procedure	Price
Sagging breasts, satisfactory volume	Mastopexy alone	€4,000 to €7,500
Sagging and deflated breasts	Mastopexy with implants	€6,000 to €8,500
Sagging breasts, empty upper chest, without implants	Mastopexy with lipofilling	€6,000 to €8,500
Sagging and overly large breasts	Breast reduction with lift	€3,000 to €5,000 when covered by the Assurance Maladie
Pseudoptosis (only volume lacking)	Augmentation with implants or lipofilling	See the procedure page

Frequently asked questions

References

• MD thesis of Dr Victor Médard de Chardon on breast augmentation with implants, Nice Faculty of Medicine, 2008.
• Flageul G. Chirurgie de la ptose mammaire [Surgery for breast ptosis]. Encyclopédie médico-chirurgicale, Paris.