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

Model Number	MF-410375
Medical Device Problem Code	Device Appears to Trigger Rejection (1524)
Health Effect - Clinical Code	Capsular Contracture (1761)
Date of Event	09/09/2021
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.The event of capsular contracture is a physiological complication and analysis of the device generally does not assist allergan in determining a probable cause for this event.A review of the device history record has been completed.No deviations or non-conformances noted.Reason for reoperation: patient who has textured allegan implants and capsular contracture grade iii.
Event or Problem Description
Healthcare professional reported right side capsular contracture, baker grade iii.Device remains implanted.
Event or Problem Description
Healthcare professional later reported concern with product.Device has been explanted.
Additional Manufacturer Narrative
Additional, changed, and/or corrected data: a.4, b.5, d.6.B, d.9, g.2, h.3, h.6.
Additional Manufacturer Narrative
Device evaluation: the device related to the reported event of capsular contracture and anxiety¿product/procedure was received on dec 07, 2021 with lot number 2817217.Visual analysis of the returned device identified 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 issues found related with the manufacturing.
Event or Problem Description
Healthcare professional reported right side capsular contracture, baker grade iii.Healthcare professional later reported "textured" removal.Device has been explanted.

• 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
• Manufacturer (Section G): ALLERGAN (COSTA RICA); 900 parkway global park; zona franca
• Manufacturer Contact: chris sprague ; 12331-a riata trace parkway; building 3; austin, TX 78727 ; 8479375615
• MDR Report Key: 12599765
• Report Number: 9617229-2021-52321
• Device Sequence Number: 11561591
• Product Code: FTR
• UDI-Device Identifier: 10888628003477
• UDI-Public: 10888628003477
• Combination Product (Y/N): N
• Initial Reporter State: OR
• Initial Reporter Country: US
• PMA/510(K) Number: P040046
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Device Explanted Year: 2021
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 01/14/2022

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: 09/13/2020
• Device Model Number: MF-410375
• Device Catalogue Number: MF-410375
• Device Lot Number: 2817217
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/07/2021
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 09/16/2021
• Supplement Date Received by Manufacturer: 11/16/2021; 12/20/2021
• Initial Report FDA Received Date: 10/08/2021
• Supplement Report FDA Received Date: 12/16/2021; 01/14/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 10/13/2015
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 43 YR
• Patient Sex: Female
• Patient Weight: 57 KG