ࡱ> G !bjbjَ 4z]0000<6<6<6P6P6P6P6P66P6X7 CCCCD K|aOXXXXXXX$|Yp[X<6!QD"D!Q!QXES00CC37ESESES!Q0N&C<6CXP6P60000!QXESFESX~'<6XC74`=P6P6S@XINTRERNATIONAL BREAST IMPLANT REGISTRYPATIENT INFORMATIONDate of birth  FORMCHECKBOX  FORMCHECKBOX  /  FORMCHECKBOX  FORMCHECKBOX  /  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  DD/MM/YYYY Gender  FORMCHECKBOX M  FORMCHECKBOX F  FORMCHECKBOX N/ASURGEON INFORMATIONAPSI membership no.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX IMPLANT INFORMATIONManufacturer:  FORMCHECKBOX McGhan  FORMCHECKBOX  Mentor  FORMCHECKBOX Lab Sebbin  FORMCHECKBOX Silimed  FORMCHECKBOX Bioplasty  FORMCHECKBOX Biosil  FORMCHECKBOX  Other Left Implant: Lot No.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  NominalVolume  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  cc Serial No.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Actual Volume  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  ccManufacturer  FORMCHECKBOX McGhan  FORMCHECKBOX  Mentor  FORMCHECKBOX Lab Sebbin  FORMCHECKBOX Silimed  FORMCHECKBOX Bioplasty  FORMCHECKBOX Biosil  FORMCHECKBOX  Other Right Implant: Lot No.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  NominalVolume  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  cc Serial No.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Actual Volume  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  ccType of Implant:  FORMCHECKBOX  Smooth  FORMCHECKBOX Textured  FORMCHECKBOX Double lumen  FORMCHECKBOX Expandable Prosthesis  FORMCHECKBOX Tissue expander  FORMCHECKBOX OtherType of filler:  FORMCHECKBOX Saline  FORMCHECKBOX Silicone gel  FORMCHECKBOX Cohesive Gel  FORMCHECKBOX Hydrogel  FORMCHECKBOX OtherIMPLANT OPERTATION DETAILDate of operation :  FORMCHECKBOX  FORMCHECKBOX / FORMCHECKBOX  FORMCHECKBOX / FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  DD/MM/YYYY Indication:  FORMCHECKBOX Cosmetic augmentation  FORMCHECKBOX Replacement  FORMCHECKBOX Following mastectomy  FORMCHECKBOX For congenital malformationIncision:  FORMCHECKBOX Axillary  FORMCHECKBOX Inframammary  FORMCHECKBOX Periareolar  FORMCHECKBOX Trasumbilical  FORMCHECKBOX Mastectomy scarPosition:  FORMCHECKBOX Submammary  FORMCHECKBOX Subpectoral  FORMCHECKBOX subcutaneous Technique:  FORMCHECKBOX  Implant only  FORMCHECKBOX  Implant +Myocutaneous flap  FORMCHECKBOX Implant with mastopexyEXPLANT OPERATION DETAILSDate of original implant operation(if known):  FORMCHECKBOX  FORMCHECKBOX / FORMCHECKBOX  FORMCHECKBOX / FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  DD/MM/YYYYYDate of Explant operation:  FORMCHECKBOX  FORMCHECKBOX / FORMCHECKBOX  FORMCHECKBOX / FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  DD/MM/YYYYYExplanted breast implant information (if known):Manufacturer  FORMCHECKBOX McGhan  FORMCHECKBOX  Mentor  FORMCHECKBOX Lab Sebbin  FORMCHECKBOX Silimed  FORMCHECKBOX Bioplasty  FORMCHECKBOX Biosil  FORMCHECKBOX  Other Left Implant: Lot No.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  NominalVolume  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  cc Serial No.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Actual Volume  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  ccManufacturer  FORMCHECKBOX McGhan  FORMCHECKBOX  Mentor  FORMCHECKBOX Lab Sebbin  FORMCHECKBOX Silimed  FORMCHECKBOX Bioplasty  FORMCHECKBOX Biosil  FORMCHECKBOX  Other Right Implant: Lot No.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  NominalVolume  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  cc Serial No.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Actual Volume  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  ccType of Implant  FORMCHECKBOX  Smooth  FORMCHECKBOX Textured  FORMCHECKBOX Double lumen  FORMCHECKBOX Expandable Prosthesis  FORMCHECKBOX Tissue expander  FORMCHECKBOX OtherType of filler:  FORMCHECKBOX Saline  FORMCHECKBOX Silicone gel  FORMCHECKBOX Cohesive Gel  FORMCHECKBOX Hydrogel  FORMCHECKBOX OtherAge of implant (if original implant operation date unknown):  FORMCHECKBOX  FORMCHECKBOX years  FORMCHECKBOX  FORMCHECKBOX monthsIndication for explantation: FORMCHECKBOX Rupture  FORMCHECKBOX capsular contracture  FORMCHECKBOX infection  FORMCHECKBOX implant shifted  FORMCHECKBOX position change (above or below muscle) FORMCHECKBOX Malignancy (answer both 1&2) 1.stage  FORMCHECKBOX 1  FORMCHECKBOX 2  FORMCHECKBOX 3  FORMCHECKBOX 4 2.Diagnostic tool used to identify presence 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