MAUDE Adverse Event Report: ALLERGAN (COSTA RICA) STYLE 168 SALINE FILLED BREAST IMPLANT; PROSTHESIS, BREAST, INFLATABLE, INTERNAL, SALINE

Model Number	168-480
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	10/15/2015
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Information contained in this report was previously submitted through asr on 29/jul/2016.A review of the device history record has been completed.No deviations or non-conformances noted.Device evaluation: visual analysis of the returned device identified: opening, wear abrasion, crease fold and yellow particles in the inside in the shell.Leak test was performed and found opening on the anterior/posterior.A microscopic analysis was performed which identified a striated edge opening, consistent with use of a surgical tool and sharp opening on the posterior side.The fill test inspection was performed, the result is no blockage.Based on the device analysis the final assessment is: striated edge opening on anterior side due to surgical damage and a sharp opening on posterior assessed as an unidentified (tear) opening.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: deflation and exchange due to concern with product.
Event or Problem Description
Patient reported right side "deflation and rippling." healthcare professional reported right side deflation and exchange due to concern with product.Patient also reported "memory loss and joint pain."; these events are not device related.Device was explanted.

• Brand Name: STYLE 168 SALINE FILLED BREAST IMPLANT
• Common Device Name: PROSTHESIS, BREAST, INFLATABLE, INTERNAL, SALINE
• Manufacturer (Section D): ALLERGAN (COSTA RICA); 900 parkway global park; zona franca
• MDR Report Key: 11735594
• Report Number: 9617229-2021-00470
• Device Sequence Number: 3438817
• Product Code: FWM
• UDI-Device Identifier: 10888628000872
• UDI-Public: 10888628000872
• Combination Product (Y/N): N
• Initial Reporter State: OK
• Initial Reporter Country: US
• PMA/510(K) Number: P990074
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Device Explanted Year: 2021
• Reporter Type: Manufacturer
• Report Source: consumer,health professional
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 04/27/2021

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: 09/10/2018
• Device Model Number: 168-480
• Device Catalogue Number: 168-480
• Device Lot Number: 2660726
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/31/2021
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 03/30/2021
• Initial Report FDA Received Date: 04/27/2021
• 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: 43 YR