Breast Q&A: What’s the Best Way to Correct Grade 1 Breast Ptosis (Sagging)? Implant, Lift or Both?

Question – What is the best way to correct breast ptosis, high or moderate profile implants, a breast lift or both?

Stage I Breast Ptosis

Breast sagging after pregnancy

I am 36 years old, breastfed 2 kids, and have lost volume in my breasts. I have some sagging but my nipple is still over the fold. I weigh 130 pounds and am very fit and toned.

I am 5″4″ and my breast size is a 34B. Before my kids I was a 34C cup. When I was breastfeeding I was a 34D cup. I would like to be a D cup and wonder what type of procedure would be best to correct my ptosis?

Answer – Since you have a small amount of glandular ptosis (pseudoptosis), you not only want to fill-OUT, but lift-UP a little as well. Therefore, my approach would be a dual plane breast augmentation, which would fill out the inferior/lower pole nicely, give you muscle coverage across the upper two thirds of the breast and a nice, slightly lifted appearance.

More specifically, given your body measurements and photo (which shows pseudoptosis with mild Grade 1 ptosis), I suspect that 450cc moderate plus profile implants are needed to give you both the breast size (D cup) and breast lift you desire.

How To Classify/Grade Breast Ptosis

Simply put, grade 1, 2 or 3 glandular ptosis, which refers to how far the areola is sagging below the inframammary fold beneath the breast, the lower attachment point of the breast to the chest wall.

  • Grade 1: Mild Ptosis – The nipple is at the level of the inframammary fold, but most of the breast tissue is below the nipple.
  • Grade 2: Moderate Ptosis – The nipple is located below the inframammary fold and below the majority of the bottom breast tissue.
  • Grade 3: Advanced Ptosis – The nipple is far below the inframammary fold and points towards the floor.
  • Pseudoptosis – The nipple lies above or at the level of the inframammary fold while the majority of the breast has descended below the level of the fold. This is not true ptosis, or sagging.
Diagram of breast ptosis (drooping/sagging) degrees/stages

The degrees/stages of breast ptosis (drooping/sagging)

What Causes Breasts To Sag?

Before jumping into procedure options to correct Grade 1 ptosis, I first want to briefly explore the causes and effects of ptosis. There are many reasons why breasts droop, sag and deflate over time. Structurally, as breasts lose firmer glandular tissue, the body replaces it with fatty tissue, which is softer and more prone to drooping/sagging. And since breasts naturally contain no muscle, they are very susceptible to the effects of gravity and aging. All women will experience some degree of ptosis, or sagging of their breasts as they grow older, but every woman will experience the process differently depending on how they score on the following 5 measures:

  • skin elasticity
  • cigarette smoking
  • number of pregnancies
  • breast size before pregnancy
  • high body mass index (BMI)

Eventually, all breasts yield to gravity, but cigarette smoking speeds up the process by breaking down proteins in the skin called elastin, which control skin elasticity. Less elastic skin = more sagging. Breastfeeding or weight loss are also common contributors to breast deflation and droop. Numerous studies have shown that the expansion and contraction which occurs during pregnancy exacerbates the potential for ptosis, with the effects increasing with each additional pregnancy.

n.b. a recent and widely reported study of twins showed that breast feeding, daily moisturizing and hormone replacement therapy effectively slowed down the aging and sagging of breasts.

How To Correct Pseudoptosis & Grade 1 Breast Ptosis (Sagging)

There are several procedure options for correcting pseudoptosis and Grade 1 ptosis. In cases of pseudoptosis, a dual plane breast augmentation using appropriately sized implants can create enough projection, fill and nipple-areola rotation and elevation to produce an attractive, mastopexy-free result that will hold up well over time.

Breast implant position options - submuscular vs subglandular vs subfascial vs dual plane

Breast implant position options: submuscular vs subglandular vs subfascial vs dual plane

By positioning the implant partially behind the breast tissue (subglandular) and partially under the pectoral muscle (submuscular), between .5cm and 1cm of lift can be achieved without the need for a vertical (lollipop), peri-areolar or circum-areolar (“donut” or Benelli) incision. The case below is a good example of how effective a well performed dual plane augmentation can be at correcting glandular pseudoptosis:


Before & after dual-plant augmentation to correct pseudoptosis. Click here to view the complete set.

In breasts that have enough sag, droop and/or deflation to be classified as Grade 1, some type of breast lift (mastopexy) is needed to tighten loose skin and elevate the nipple-areolas. Whether a vertical (lollipop), peri-areolar or circum-areolar (“donut” or Benelli) incision is needed will depend on an array of factors (which I plan to outline in a future post).

In most cases of grade 1 or 2 ptosis, a small-to-medium sized implant is needed to regain noticeable upper-pole fullness and achieve the fuller, perkier and more youthful looking shape some many of my patients desire. See below for a good example of the amount of droop, sag and deflation can be corrected by simultaneously lifting and augmenting the breasts in a single procedure:

Breast Augmentation (Mastopexy) Before and After - Grade I Ptosis

Before & after breast augmentation + lift utilizing 375cc moderate saline implants filled to 410cc bilaterally to correct 1st degree ptosis. Click here to view the complete set.

In closing, my final bit of advice is simply that you seek out the most experienced and talented ABS-certified plastic surgeon you can find because your case is by no means a ‘straight forward’ augmentation and/or mastopexy. Achieving breasts that not only project an attractive, perky shape but also hold up over time (re: 10+ years) will certainly require a high degree of skill and precision on the part of your surgeon. So take your time and choose wisely.

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