Brand Name | STYLE 115 SILICONE GEL FILLED BREAST IMPLANT |
Type of Device | PROSTHESIS, BREAST, NONINFLATABLE, INTERNAL, SILICONE GEL-FILLED |
Manufacturer (Section D) |
ALLERGAN (COSTA RICA) |
900 parkway global park |
zona franca |
la aurora de heredia |
CS |
|
Manufacturer (Section G) |
ALLERGAN (COSTA RICA) |
900 parkway global park |
zona franca |
la aurora de heredia |
CS
|
|
Manufacturer Contact |
terry
ingram
|
12331-a riata trace parkway |
building 3 |
austin, TX 78727
|
8479366324
|
|
MDR Report Key | 18740029 |
MDR Text Key | 335766772 |
Report Number | 9617229-2024-02780 |
Device Sequence Number | 1 |
Product Code |
FTR
|
Combination Product (y/n) | N |
Reporter Country Code | KS |
PMA/PMN Number | P020056 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Foreign,Consumer |
Reporter Occupation |
Other
|
Type of Report
| Initial,Followup,Followup |
Report Date |
03/28/2024 |
2 Devices were Involved in the Event: |
1
2
|
1 Patient was Involved in the Event |
|
Date FDA Received | 02/20/2024 |
Is this an Adverse Event Report? |
Yes
|
Is this a Product Problem Report? |
No
|
Device Operator |
Health Professional
|
Device Expiration Date | 05/01/2017 |
Device Catalogue Number | 115-272 |
Device Lot Number | 2293501 |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
No
|
Date Manufacturer Received | 03/14/2024 |
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Date Device Manufactured | 06/01/2012 |
Is the Device Single Use? |
Yes
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Initial
|
Patient Sequence Number | 1 |
Patient Outcome(s) |
Required Intervention;
|
Patient Age | 38 YR |
Patient Sex | Female |
Patient Weight | 48 KG |
Patient Race | Asian |
|
|