June 6, 2001 - In conjunction with Dr. Leroy Young of St. Louis, MO, I am pleased to bring you a quite comprehensive survey, the results of which will be very helpful to future augmentation patients as well as women who currently have breast implants. The survey contains a total of 120 questions but can be completed in less than 15 minutes. Your help in taking the time to answer is greatly appreciated!
All responses will be kept anonymous. Results will be posted after a sufficient number of visitors have completed the survey. Nicole
Please - answer all questions (unless they clearly don't apply). Surveys submitted without answers for AGE, STATE, etc. will be discarded.
1
Month January February March April May June July August September October November December (Click here to choose) Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 (Click here to choose) Year
2
Current Age
3
Height
Note: Some of the questions that follow ask for information about your breasts or implants before and after breast implantation. If you have not yet received implants, please answer only those questions that seem to apply to you now.
4. Please fill in the following information regarding your breast size before and after breast augmentation:
Band Size before (e.g., 32, 34) Cup Size before (e.g., A, B) Band Size after (e.g., 32, 34) Cup Size after (e.g., A, B)
5
Less than 90 lbs. 91-100 lbs. 101-110 lbs. 111-120 lbs. 121-130 lbs. 131-140 lbs. 141-150 lbs. 151-160 lbs. 161-170 lbs. 171-180 lbs. 181-190 lbs. More than 190 lbs.
6. What is your current weight (after augmentation)?
Rate your general satisfaction with your current breast appearance using the following 5-point rating scale (1 = very dissatisfied; 5 = very satisfied):
7. Appearance in clothes
(very dissatisfied) 1 2 3 4 5 (very satisfied)
8. Appearance in swimsuit
9. Appearance in nude
Rate your general satisfaction with the current appearance of different areas of your body using the following 5-point rating scale (1 = very dissatisfied; 5 = very satisfied):
10. Current appearance of Breasts
11. Current appearance of Face (features, complexion)
12. Current appearance of Mid torso (waist, stomach)
13. Current appearance of Lower torso (hips, buttocks)
14. Current appearance of Thighs
15. Current appearance of Body as a whole
16. Current Height/weight ratio
Please evaluate your current breast symmetry/asymmetry?
17. Are both your breasts basically the same size?
Yes No
18. Are both your breasts basically the same shape?
Please indicate your reasons for getting breast implants by checking a number on this 5-point scale. You may have more than one very important reason (1 = not important; 5 = very important):
19. Look better in clothes
(not important) 1 2 3 4 5 (very important)
20. Look better without clothes
21. Appear more feminine
22. Be less self-conscious
23. Have larger breasts
24. Have cleavage
25. Feel more confident
26. Correct sagging
27. Compensate for weight change
28. Feel better about myself
29. Please husband/significant other
30. Regain size or shape of breasts before or during pregnancy
31. Other
Specify
32
Completely Mostly Partly Not at all Don't have implants yet
33. Have you had other plastic surgery besides breast augmentation?
34. Did anyone encourage you to pursue breast augmentation?
35. If yes, who? (check all that apply):
Husband/significant other Friend Relative Co-worker Other
36. Have you seen or heard advertisements about breast implants?
37. If yes, from which media source? (check all that apply)
Magazine Newspaper Radio TV Web Site
If you HAVE NOT gotten breast implants yet, please skip to the section on BREAST PAIN (question 75)
Please answer the following two questions if you HAVE NOT had breast augmentation surgery yet.
38. When do you plan to have breast augmentation surgery? (check one)
Within 3 months 3 to 6 months 6 to 9 months 9 to 12 months Undecided
39. How long have you been considering breast augmentation?
Months or Years
For those who have had augmentation, tell us about your breast augmentation experience:
40. Have you had other breast implants prior to the ones you have now?
41. How many total implantation surgeries have you had? (type in a number, not the word - for example - 1, not "one").
Note: If you have had more than one implant-related surgery, please fill out the appropriate number of Reoperation Surveys for each set of implants you have had.
For the remainder of this survey, please answer based upon the implants you have NOW.
42. How long have you had your breast implants?
Years Months
43
Month January February March April May June July August September October November December (Click here to choose) Year
44
45
Silicone gel Saline Double lumen (gel surrounded by saline) Other Don't know
46. How was the size of your implants determined? (check all that apply)
My surgeon and I decided together My surgeon chose the size I told my surgeon what bra size I wanted to be I showed my surgeon photographs from a magazine or website My breast width was measured I experimented with padded bras or bra fillers
47. Please rate the feel of your right breast using a 5 point scale (1 = too hard; 5 = natural feeling):
(too hard) 1 2 3 4 5 (natural feeling)
48. Please rate the feel of your left breast using a 5 point scale (1 = too hard; 5 = natural feeling):
49. Who performed your breast implant surgery?
Plastic surgeon Other type of surgeon
50. Did your surgeon prepare you for what to expect after augmentation surgery?
51. Did your surgeon take time to answer your questions?
52. Did your surgeon take time to listen to and understand your concerns?
Did your surgeon tell you about the following complications that sometimes occur after breast augmenation surgery? (answer each question separately)
53. Implant rupture or deflation?
Yes No Don't remember
54. Changes in breast sensation?
55. Breast hardness?
56. Infection?
57. Bleeding?
58. Breast pain?
59. Less clear mammograms?
60. The need for additional implant surgery?
Have any of the following areas of your life changed since you got breast implants? Specify the change applicable to each:
61. Marriage or dating
Better Same Worse
62. Sex life
63. Work/career
64. Social life
65. Life in general
66. Self-confidence
67. Wardrobe options
68. Overall appearance
69. Do you receive more compliments on your appearance since breast augmentation?
70. Has anyone criticized you for getting breast implants?
71. Overall, are you happy about your decision to get breast implants? (choose one number on this 5-point scale - 1 = horrible decision; 5 = great decision):
(horrible decision) 1 2 3 4 5 (great decision)
72. Based on your experience with breast implants, would you recommend breast augmentation to friends or family members?
73. Have you been involved in a lawsuit about your breast implants?
74. If yes, what type of lawsuit were you involved in (choose one)?
Member of the national class action lawsuit Individual filing a personal claim Both
TELL US ABOUT ANY BREAST PAIN
75. Do you ever have breast pain?
Yes [Go to question 76] No [Go to question 86]
76. If you have or had breast pain before breast augmentation, which of the following does (or did) the pain seem to be associated with? (check all that apply)
Nursing Menstrual cycle Caffeine Eating chocolate Cysts None of the above
77. If you have experienced breast pain after breast augmentation, which of the following does (or did) the pain seem to be associated with? (check all that apply)
Breast Implants (including capsular contracture or other complication) Nursing Menstrual cycle Caffeine Eating chocolate Cysts None of the above
78. Where do you typically have pain (before augmentation)?
Both breasts Right breast only Left breast only Not applicable
79. Where do you typically have pain (after augmentation)?
80. If you have breast pain in your right breast, which number (on a scale of 1 to 10) best matches the severity of your typical breast pain?
(least I ever had) 1 2 3 4 5 6 7 8 9 10 (worst I ever had)
81. If you have breast pain in your left breast, which number (on a scale of 1 to 10) best matches the severity of your typical breast pain?
82. If you have/had breast pain before augmentation, how many days a month (on average) do you have pain?
1-2 days 3-5 days 6-10 days 11-20 days Most days
83. If you have breast pain after augmentation, how many days a month (on average) do you have pain?
84. If you have breast pain, has its severity changed since you got implants?
More severe Less severe About the same Don't have implants
85. If you have breast pain, has its frequency changed since you got implants?
More frequent Less frequent About the same Don't have implants
TELL US ABOUT YOUR MAMMOGRAMS
86. Have you ever had a mammogram?
87. If yes,
how many?
88
89. If you do not get regular mammograms, why not? (check all that apply):
Not old enough Fear of discomfort Fear of finding out I might have cancer Didn't know I needed to Fear of radiation Difficulty getting to mammography facility Worried my implant might rupture Couldn't find time Not a priority Other
90. If your answer included other, please specify . . .
Other reason
91
Yes No Haven't had a mammogram with implants
PREGNANCY AND NURSING
92. Have you given birth to any children?
Yes [Go to question 93] No [Go to question 101]
93. How many children did you give birth to before augmentation?
0 1 2 3 4 5 More than 5
94. How many children did you breastfeed before augmentation?
95. If you nursed any children before augmentation, how long did you nurse them?
1-4 weeks 2-3 months 4-5 months 6-8 months 9-12 months
96. How many children did you give birth to after augmentation?
97. How many children did you breastfeed after augmentation?
98. If you nursed any children after augmentation, how long did you nurse them?
99. If you nursed a child before augmentation, please indicate whether you had any of the following problems by checking any of the boxes below that apply:
Insufficient milk production Breast infection Nipple sensitivity "Fussy" baby Schedule conflicts Difficulty finding privacy Didn't have any problems
100. If you nursed a child after augmentation, please indicate whether you had any of the following problems (check all that apply):
Insufficient milk production Breast infection Nipple sensitivity "Fussy" baby Schedule conflicts Difficulty finding privacy Afraid to breast feed with implants Didn't have any problems
FAMILY HISTORY OF BREAST CANCER
101. Do you have a close blood relative who has had breast cancer?
Yes [Go to question 102] No [Go to question 106]
102. If yes, please identify which relative(s) (check all that apply):
My Mother Mother's mother Mother's sister (1) Mother's sister (2) Father's mother Father's sister (1) Father's sister (2) My Sister (1) My Sister (2)
103. Have you ever had breast cancer?
104. If yes, were you diagnosed with breast cancer before you got breast implants?
105. If you have/had a blood relative with breast cancer, what was her approximate age at diagnosis?
My Mother Mother's mother Mother's sister (1) Mother's sister (2) Father's Mother Father's Sister (1) Father's Sister (2) My Sister (1) My Sister (2)
MISCELLANEOUS INFORMATION
106. What state or province do you live in?
State Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose)
107
Major urban area Major city in my state Medium-size city Town Rural Area
108. What is your marital status
Single Married Divorced Widowed Separated Member of unmarried couple
109. What is the highest level of schooling you have completed?
Junior high High school Some college College graduate Some graduate school Graduate or professional degree
110. What is the average annual income of your household?
Less than $25,000 $25,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 or more
111. What is your email address (without a valid email address, we cannot process your survey results and they will be discarded)? We will use your address in the event that there are questions which need clarification. You may also also be sent information in the future about breast augmentation.
Email address
REOPERATION SURVEY - Answer if you have had more than one breast implantation surgery. At the end of this section, there will be an opportunity to answer the same questions for each successive reoperation if you have had multiple reoperations.
IF YOU HAVE NOT HAD MORE THAN ONE SURGERY, CLICK HERE
112. When was your first reoperation to revise your breast augmentation surgery?
113
Both Left Right
114. What type of implants did you have before reoperation?
Silicone Gel Saline Double Lumen (gel and saline) Other Don't know
115. What type of implants did you have after reoperation?
Silicone Gel Saline Double Lumen (gel and saline) Other Don't know Implants were not replaced
116. At the time of this reoperation, did you have an implant(s) removed (whether replaced or not)?
117. If you had an implant(s) removed, what was the condition of the left implant:
Intact Small Leak Rupture or deflation Don't know
118. If you had an implant(s) removed, what was the condition of the right implant:
119. If you had an implant removed, what other procedure was done?
None, implant removal only (no replacement) Implant replaced with new implant Old implant re-used Mastopexy (breast lift) without implant Mastopexy (breast lift) plus implant Transfer of tissue flap from another part of body
120. Why did you have this reoperation? (check all that apply)
Known or suspected implant rupture or deflation Capsular contracture (breasts too hard and/or round) Concern about rupture because implants were old Wanted larger size implants Wanted smaller size implants Breast size or shape was not symmetrical (in absence of rupture or deflation) Implant not positioned properly Implant had moved or migrated Skin overlying implant looked wrinkled or rippled Breast felt abnormal to touch because of implant Infection around implant Implant had extruded through skin Breast pain or burning Physical symptoms other than breast pain Breast cancer diagnosis Revision of implant pocket to improve breast shape or position Concern about safety of silicone Cosmetic revision of scar Improve accuracy of mammograms Wanted to move implants from above the pectoralis muscle to below the muscle Other
121. Did your revisional surgery successfully address your reason for reoperation?
Completely Mostly Partly No Only temporary success Successful to date
REOPERATION SURVEY # 2 - Answer if you have had a third surgery. At the end of this survey, there will be an opportunity to answer the same questions for each successive reoperation.
IF YOU HAVE NOT HAD MORE THAN TWO SURGERIES, CLICK HERE
122. When was your second reoperation to revise your breast augmentation surgery?
123
124. What type of implants did you have before reoperation?
125. What type of implants did you have after reoperation?
126. At the time of this reoperation, did you have an implant(s) removed (whether replaced or not)?
127. If you had an implant(s) removed, what was the condition of the left implant:
128. If you had an implant(s) removed, what was the condition of the right implant:
129. If you had an implant removed, what other procedure was done?
130. Why did you have this reoperation? (check all that apply)
131. Did your revisional surgery successfully address your reason for reoperation?
REOPERATION SURVEY # 3- Answer if you have had a fourth surgery. At the end of this survey, there will be an opportunity to answer the same questions for each successive reoperation if you have hada third reoperation.
IF YOU HAVE NOT HAD MORE THAN THREE SURGERIES, CLICK HERE
132. When was your third reoperation to revise your breast augmentation surgery?
133
134. What type of implants did you have before reoperation?
135. What type of implants did you have after reoperation?
136. At the time of this reoperation, did you have an implant(s) removed (whether replaced or not)?
137. If you had an implant(s) removed, what was the condition of the left implant:
138. If you had an implant(s) removed, what was the condition of the right implant:
139. If you had an implant removed, what other procedure was done?
140. Why did you have this reoperation? (check all that apply)
141. Did your revisional surgery successfully address your reason for reoperation?
REOPERATION SURVEY# 4 - Answer if you have had a fifth breast surgery. At the end of this survey, there will be an opportunity to answer the same questions for each successive reoperation if you have had a fourth reoperation.
IF YOU HAVE NOT HAD MORE THAN FOUR SURGERIES, CLICK HERE
142. When was your fourth reoperation to revise your breast augmentation surgery?
143
144. What type of implants did you have before reoperation?
145. What type of implants did you have after reoperation?
146. At the time of this reoperation, did you have an implant(s) removed (whether replaced or not)?
147. If you had an implant(s) removed, what was the condition of the left implant:
148. If you had an implant(s) removed, what was the condition of the right implant:
149. If you had an implant removed, what other procedure was done?
150. Why did you have this reoperation? (check all that apply)
151. Did your revisional surgery successfully address your reason for reoperation?
152. Who manufactured your implants?
Mentor McGhan Other Not Sure
153. If your answer to the preceding question was other, please specify the manufacturer:
Name of Manufacturer
154
Round Contoured (anatomically shaped) Not sure
155. What type of surface do your implants have?
Smooth Textured Polyurethane Not sure
156. What position are your implants in?
Above the muscle (subglandular) Under the muscle (submuscular) Not sure
157. Smoking History
Never smoked Former smoker Current smoker
158. If you CURRENTLY smoke, how much do you smoke?
Less than a pack a day 1-2 packs a day More than 2 packs a day
159. Which statement best describes your typical pattern of alcohol consumption?
I never drink alcohol I rarely drink alcohol (once a month or less) I have a few drinks a month I have a few drinks a week I have at least one drink most days
PHYSICAL SYMPTOMS: In the early 1990s, some women with breast implants complained of physical symptoms. Since then, many large scientific studies have found no connection between these reported symptoms and breast implants. Even so, we'd like to know if you have experienced any of the following symptoms consistently for periods longer than 2 months at a time.
160. Joint Pain
Yes, before I had breast implants Yes, after I had breast implants No
161. Joint Swelling
162. Muscle aches or pains
163. Muscle Weakness
164. Numbness or tingling in arms or legs
165. Abnormal fatigue
166. Difficulty sleeping
167. Dry eyes
168. Dry mouth
169. If you answered yes to any of the above, is there a reason for your symptom(s)? (examples might be an injury with long-term consequences, a disease diagnosis, depression, medication side effects, etc.) Specify any such condition(s):
Have you ever been diagnosed with any of the following chronic diseases?
170. Rheumatoid arthritis
171. Osteoarthritis (from aging or "wear and tear")
172. Lupus erythematosus
173. Scleroderma
174. Sjögren's syndrome
175. Fibromyalgia
176. Rheumatoid arthritis
177. Other disease not listed
178. Please specify the disease referred to in the preceding question (if you feel comfortable doing so):
Disease
This questionnaire was created using Perseus SurveySolutions.