Date of Birth:
For Explant patients, please tell us:
How long have you had your implants?
What type are your implants?
Please include information like silicone vs saline, smooth vs. textured, and profile information here.
What size are your implants (in cc's)?
To your knowledge, are your implants placed under or over your muscle?
What size were you prior to having implants put in?
Example: 34B, 32A, 38D
Are you feeling symptomatic?
Why do you want to remove your implants?
Have you been pregnant previously or ever breast fed?
If applicable to you, please include how long you breastfed for.
Do you have breast pain?
Do you have normal nipple sensation?
Have you ever had a revision surgery on your breast?
Please include reason for revision surgery, when the surgery was performed, and if the revision surgery was due to a complication- for example: seroma, hematoma, infection, etc.
Have you ever had a breast lift?
If you are unsure, please notate where the incisions from your surgery are.
Have you ever had any imaging other than a mammogram done?
If so, please indicate the results of the imaging and what year the imaging was performed.
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