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

Model Number	100042-04
Medical Device Problem Code	Patient-Device Incompatibility (2682)
Health Effect - Clinical Code	Necrosis (1971)
Date of Event	12/19/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Based on the information provided, no conclusions can be made.As reported, the patient experienced post-op complication necrosis.Medical affairs has assessed the patient¿s postoperative course as not-serious and likely related to the study device.No lot number has been provided; therefore, a review of the manufacturing records is not possible.Not returned.
Event or Problem Description
Per clinical trial (b(4): on (b)(6) 2018, patient underwent bilateral mastopexy; inferior pedicle, using a full vertical and horizontal t incision.2 pieces of galashape (galaflex 3d) were used.Concomitant procedure was vaser assisted liposuction to posterior hips and lateral thighs.On (b)(6) 2018, left breast necrosis was reported.¿probably tiny left breast fat necrosis¿.No action was taken.Resolved without sequelae on (b)(6) 2019.Review by medical affairs identifies the reported necrosis is likely related to the device and not serious.

• Brand Name: GALAFLEX 3D
• 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: 15101769
• Report Number: 1213643-2022-00528
• Device Sequence Number: 12119496
• Product Code: OOD
• UDI-Device Identifier: 00855920006171
• UDI-Public: (01)00855920006171
• Combination Product (Y/N): N
• Initial Reporter State: CO
• Initial Reporter Country: US
• PMA/510(K) Number: K161092
• 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): 07/14/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 100042-04
• Device Catalogue Number: SH3D04
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 07/12/2022
• Initial Report FDA Received Date: 07/26/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• 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: Other
• Patient Age: 60 YR
• Patient Sex: Female
• Patient Weight: 64 KG