Breast Implant Survey
(PLEASE DISTRIBUTE TO ALL BREAST FOLLOW-UPS OR CONSULTS)
The goal of the survey is to determine your perception about breast implants. The results of the survey will be completely anonymous and is to be used as part of a research project that aims to study the impact of media on the general population with regards to breast implants. Your participation would be greatly appreciated and aid us in our study. If you have any questions, please do not hesitate to ask Dr. Davison.
Dr. Peter Davison
Division of Plastic & Reconstructive surgery McGill University Health Centre
______________________________________________________________________________
1) Age: __________
2) Do you have a history of breast cancer?
□ yes□ no
3) Do you currently or did you previously have breast implants?
□ yes□ no
4) Are you considering breast reconstruction with implants?
□ yes□ no
5) Have you heard of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)?
□ yes□ no
6) If so, where have you heard about breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)? Select all that apply
□ News article
□ Radio
□ Television
□ Social Media
□ Friends/Family
□ Doctor’s office
□ Other (please specify): _________________________________________________________
7) How has the emergence of BIA-ALCL affected your perception of breast implant surgery?
□ Not at all. (I am still interested in getting breast implants)
□ I am now less likely to get breast implants. I need more information to decide
□ I will never get breast implants because of the emergence of BIA-ALCL
□ I would now like to remove my implants because of BIA-ALCL
□ I never considered breast implants
□ N/A
□ Other (please specify): _________________________________________________________
8) Are you more or less likely to recommend breast implants to a family member or friend?
□ Less likely
□ Just as likely
□ More likely
□ N/A (please specify): __________________________________________________________
9) Please describe BIA-ALCL in 3-5 words:
______________________________________________________________________________
10) What is the fate of a person with BIA-ALCL?
□ All cases are curable
□ Most cases are curable
□ All cases are deadly
□ Most cases are deadly
□ I don’t know
11) Is BIA-ALCL associated with all types of implants?
□ Yes, all implants can result in BIA-ALCL
□ Only textured silicone implants have been proven to be associated with BIA-ALCL
□ Only smooth silicone implants have been proven to be associated with BIA-ALCL
□ Only saline implants have been proven to be associated with BIA-ALCL
□ I don’t know
12) Have you heard of breast implant illness?
□ yes□ no
13) If so, where have you heard about breast implant illness? Select all that apply
□ N/A
□ News article
□ Radio
□ Television
□ Social Media
□ Friends/Family
□ Doctor’s office
□ Other (please specify): _________________________________________________________
14) Please name symptoms of breast implant illness (name as many symptoms as possible):
_____________________ ________________________ ________________________
_____________________ ________________________ ________________________
_____________________ ________________________ ________________________
_____________________ ________________________ ________________________
15) How has the emergence of breast implant illness affected your perception of breast implant surgery?
□ Not at all. (I am still interested in getting breast implants)
□ I am now less likely to get breast implants. I need more information to decide
□ I will never get breast implants because of the emergence of BIA-ALCL
□ I would now like to remove my implants because of BIA-ALCL
□ I never considered breast implants
□ N/A
□ Other (please specify): _________________________________________________________
16) Are you more or less likely to recommend breast implants to a family member or friend?
□ Less likely
□ Just as likely
□ More likely
□ N/A (please specify): __________________________________________________________
