MAUDE Adverse Event Report: ALLERGAN (COSTA RICA) INSPIRA TEXTURED SILICONE GEL FILLED BREAST IMPLANT; PROSTHESIS, BREAST, NONINFLATABLE, INTERNAL, SILICONE GEL-FILLED

Model Number	TRM-445
Medical Device Problem Code	Material Rupture (1546)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	09/21/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Further information from the reporter regarding event, product, or patient details has been requested.No additional information is available at this time.Reason for reoperation: rupture and pain.
Event or Problem Description
Patient reported left side rupture and pain.Device has been explanted.
Event or Problem Description
Patient reported left side rupture and pain.Device has been explanted.
Additional Manufacturer Narrative
A review of the device history record has been completed.No deviations or non-conformances noted.Device evaluation: analysis of the returned device identified: underweight, broken on anterior and missing on anterior (0-25%).A visual and microscopic analysis was performed which identified: sharp opening and broken.A dimension measurement in the shell was performed which identified the thickness within specification.Based on the device analysis the final assessment is a sharp pattern on posterior of opening and broken device assessed as an unidentified (tear) opening.Missing shell assessed as inconclusive.
Event or Problem Description
Patient reported left side rupture and pain.Device has been explanted.

• Brand Name: INSPIRA TEXTURED SILICONE GEL FILLED BREAST IMPLANT
• Common Device Name: PROSTHESIS, BREAST, NONINFLATABLE, INTERNAL, SILICONE GEL-FILLED
• Manufacturer (Section D): ALLERGAN (COSTA RICA); 900 parkway global park; zona franca; CS
• MDR Report Key: 10950232
• Report Number: 9617229-2020-19784
• Device Sequence Number: 583472
• Product Code: FTR
• UDI-Device Identifier: 10888628008144
• UDI-Public: 10888628008144
• Combination Product (Y/N): N
• Initial Reporter Country: NL
• PMA/510(K) Number: P020056
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2008
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: company representative,consum
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 02/26/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Expiration Date: 07/22/2013
• Device Model Number: TRM-445
• Device Catalogue Number: TRM445
• Device Lot Number: 1630687
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/22/2021
• Initial Date Received by Manufacturer: 11/05/2020
• Supplement Date Received by Manufacturer: 12/08/2020; 01/22/2021
• Initial Report FDA Received Date: 12/05/2020
• Supplement Report FDA Received Date: 01/06/2021; 02/26/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 45 YR