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

Model Number	FX-410360
Medical Device Problem Code	Material Rupture (1546)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	08/26/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).A review of the device history record has been completed.No deviations or non-conformances 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: device rupture.
Event or Problem Description
Healthcare professional reported "exchange from textured to smooth implants due to the patient's concerns with the product with a right side rupture and possible bia-alcl".The device remains implanted.
Event or Problem Description
The device has been explanted.
Event or Problem Description
Healthcare professional reported "exchange from textured to smooth implants due to the patient's concerns with the product with a right side rupture and possible bia-alcl".Later reported "amorphous calcifications".Also reported "pathology revealed apocrine metaplasia/cyst", "microcysts", "usual ductal hyperplasia", "micro-papilloma's", "sclerosing adenosis", and "pseudo angiomatous stromal hyperplasia" that are not device related.The device has been explanted.
Additional Manufacturer Narrative
Device evaluation: based on the device analysis grid, the assessments of the complaint are: rupture: broken and opening observed on posterior side assessed as unidentified (tear) opening (shell thickness was within specification) and missing shell assessed as inconclusive.Anxiety-product/procedure: unable to observe as it is a medical event not related to the device.Calcification: no observed.Cyst-ndr: not applicable as the event is not related to the device.Additional observations: yellow particles observed on the surface of the shell.No further actions are required as the device was implanted.

• 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: terry ingram ; 12331-a riata trace parkway; building 3; austin, TX 78727 ; 8479366324
• MDR Report Key: 16299837
• Report Number: 9617229-2023-01686
• Device Sequence Number: 20379672
• Product Code: FTR
• UDI-Device Identifier: 10888628002975
• UDI-Public: 10888628002975
• 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: 2016
• Device Explanted Year: 2023
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 05/19/2023

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: 07/05/2020
• Device Model Number: FX-410360
• Device Catalogue Number: FX-410360
• Device Lot Number: 2788167
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 01/17/2023
• Supplement Date Received by Manufacturer: 05/01/2023; 07/12/2023
• Initial Report FDA Received Date: 02/03/2023
• Supplement Report FDA Received Date: 05/19/2023; 08/01/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 08/05/2015
• 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: 33 YR
• Patient Sex: Female
• Patient Weight: 66 KG