MAUDE Adverse Event Report: TEPHA, INC. - 3005670760 GALAFLEX 3DR; BREAST - ABSORBABLE MESH

Model Number	100043-04
Medical Device Problem Code	Patient-Device Incompatibility (2682)
Health Effect - Clinical Code	Wound Dehiscence (1154)
Date of Event	07/19/2018
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Based on the information provided, no conclusions can be made.As reported, patient experienced post-op complications of wound dehiscence.Medical affairs has assessed the patient¿s postoperative course as being serious and related to the study device.Review of the device history records confirmed the device was manufactured to specification.Wound dehiscence is a known inherent risk of the surgery/use of the device and listed as a possible complication in the adverse reaction section of the instructions for use (ifu).An additional emdr was submitted to report additional ae of ptosis.
Event or Problem Description
Per clinical trial cp-1060: on (b)(6) 2018, patient underwent bilateral augmentation mastopexy using a vertical incision.Two pieces of galaform (galaflex 3dr) were used.There were no concomitant procedures documented.On (b)(6) 2018, wound dehiscence of right breast incision was reported.Patient was treated with medication (polysporin and silver nitrate).Resolved with sequelae on unknown date.Review by medical affairs identifies as likely related to the device and serious.

• Brand Name: GALAFLEX 3DR
• Common Device Name: BREAST - ABSORBABLE MESH
• Manufacturer (Section D): TEPHA, INC. - 3005670760; 99 hayden ave suite 360; lexington MA 02421
• Manufacturer (Section G): TEPHA, INC. - 3005670760; 99 hayden ave suite 360; lexington MA 02421
• Manufacturer Contact: andrew topoulos ; 100 crossings blvd.; warwick, RI 02886 ; 8005566756
• MDR Report Key: 13953519
• Report Number: 1213643-2022-00111
• Device Sequence Number: 14520978
• Product Code: OOD
• UDI-Device Identifier: 00855920006256
• UDI-Public: (01)00855920006256
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K162922
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: Other,Study
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 03/25/2022

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: 01/07/2019
• Device Model Number: 100043-04
• Device Catalogue Number: FR3D04
• Device Lot Number: 170599
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 03/24/2022
• Initial Report FDA Received Date: 03/30/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 01/30/2018
• 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: 27 YR
• Patient Sex: Female
• Patient Weight: 72 KG