MAUDE Adverse Event Report: ALLERGAN (COSTA RICA) STYLE 410 COHESIVE SILICONE GEL FILLED BREAST IMPLANT; PROSTHESIS, BREAST, NONINFLATABLE, INTERNAL, SILICONE GEL-FILLED

Model Number	FM-410270
Medical Device Problem Code	Material Rupture (1546)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	11/30/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
A review of the device history record has been completed.No deviations or non-conformance noted.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.
Event or Problem Description
Healthcare professional reported right side rupture and exchange of textured devices due to patient's concern with product.Device has been explanted.
Additional Manufacturer Narrative
Additional, changed, and/or corrected data: d.9, h.3, h.6.
Event or Problem Description
Healthcare professional reported right side rupture and exchange of textured devices due to patient's concern with product.Device has been explanted.
Event or Problem Description
Healthcare professional reported right side rupture and exchange of textured devices due to patient's concern with product.Device has been explanted.
Additional Manufacturer Narrative
Device evaluation: visual analysis of the returned device identified yellow particles material was found on the shell and deformation.A weight test of the device was verified and the device was within specification.Cloudy after autoclave disinfection process in the gel.Based on the device analysis the final assessment is: no observations found related with the complaint reported by the physician.Additional, changed, and/or corrected data: h.3, h.6.

• Brand Name: STYLE 410 COHESIVE 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
• MDR Report Key: 11568613
• Report Number: 9617229-2021-03787
• Device Sequence Number: 4455444
• Product Code: FTR
• UDI-Device Identifier: 10888628002838
• UDI-Public: 10888628002838
• Combination Product (Y/N): N
• Initial Reporter State: MA
• Initial Reporter Country: US
• PMA/510(K) Number: P040046
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2021
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 06/03/2021

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: 03/20/2022
• Device Model Number: FM-410270
• Device Catalogue Number: FM-410270
• Device Lot Number: 3045221
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/13/2021
• Initial Date Received by Manufacturer: 02/24/2021
• Supplement Date Received by Manufacturer: 03/30/2021; 05/06/2021
• Initial Report FDA Received Date: 03/25/2021
• Supplement Report FDA Received Date: 04/27/2021; 06/03/2021
• 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: 53 YR
• Patient Weight: 59