TRAINING ONLY: Post Scan Survey - Rupture Suspected (5B)

THIS FORM IS TO BE COMPLETED BY THE SUBJECT IF THERE IS A SUSPECTED RUPTURE OF AN IMPLANT

This survey is designed to learn how you feel about possible silent rupture of your silicone gel breast implants after learning the results of the ultrasound scan. Questions refer only to your current silicone gel implants, not any implants you may have had previously. Check one answer for each question, unless otherwise indicated.

Question Title

1. As your ultrasound scan showed an implant rupture, which of the statements below apply to you? (check all that apply)

I am concerned that I didn’t know it was ruptured

I am concerned about how long the implant was ruptured

I am concerned that silicone gel is coming in contact with my body tissue

I am concerned about the time, cost or extent of surgery needed for revision

I am concerned about other potential complications

I am not concerned

Question Title

2. Would you like to revmove the ruptured implant, even if not causing symptoms?

Yes

Undecided

Question Title

3. What would prevent you from removing the ruptured implant? (check all that apply)

Concerns about cost of surgery

Concerns about downtime and/or taking time off for surgery

Concerns about physical discomfort of revision surgery

My surgeon says it is acceptable to leave it in place

Nothing would prevent me from removing the ruptured implant

Question Title

4. Which course of action are you most likely to take?

Replace the implant with another silicone gel implant, only if the costs are reduced by warranty

Replace the implant with another silicone gel implant, even if the costs are out-of-pocket

Replace the implant with an alternative to silicone gel implants (structured implant or saline implant), even if the costs are out-of-pocket

I would not replace the implant

Question Title

5. If you choose to replace your ruptured implant, when would you want it replaced?

Within 3 months

3 – 12 months

More than 12 months

I would not replace the implant

Question Title

6. If you were getting breast implants for the first time today, which of the 3 different implant types would you consider? (check all options that you would consider)

Silicone gel – natural feel, need MRI or ultrasound scans to detect silent rupture

Structured – natural feel, look in mirror to detect rupture so no scans, saline-filled

Saline – less natural feel, look in mirror to detect rupture so no scans

I would not choose to get breast implants