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

Model Number	MX-410520
Medical Device Problem Code	Device Appears to Trigger Rejection (1524)
Health Effect - Clinical Codes	Capsular Contracture (1761); Seroma (2069); Swollen Lymph Nodes/Glands (4432)
Date of Event	08/15/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
A review of the device history record has been initiated.If any new, changed or corrected information is noted, a supplemental medwatch will be submitted.The events of capsular contracture, seroma and lymphadenopathy are physiological complications and analysis of the device generally does not assist allergan in determining a probable cause for these events 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: capsular contracture baker grade unknown, seroma and lymphadenopathy.
Event or Problem Description
Patient representative reported "plaintiff underwent painful removal procedures as well as treatment, therapy, recovery, and expense associated with the removal of the biocell textured breast implant due to fear of alcl, to reduce risk of alcl, and due to symptoms consistent with alcl and fear of alcl including: mental anguish, increased risk of alcl, evaluation for alcl, explant, reconstruction, seromas, asymmetry, breast pain, heat sensations, rashes or itching, capsular contracture baker grade unknown , and mass under the arm or breast.Also reported swollen lymph nodes.Additionally, plaintiff suffered aggravation of underlying conditions including emotional distress, panic disorder, and anxiety, as well as loss of quality of life, ptsd, and depression; and other physical and emotional manifestations that are severe and ongoing.Plaintiff has not been diagnosed with bia-alcl." also reported chronic insomnia.Significant weight loss or gain, ulcer, irritable bowel/crohn's disease, chronic headache, fatigue and weakness , connective tissue disease, joint and muscle pain, nerve damage (all events are not related to the device.) this record is for the left side.The 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: terry ingram ; 12331-a riata trace parkway; building 3; austin, TX 78727 ; 8479366324
• MDR Report Key: 16731971
• Report Number: 9617229-2023-05828
• Device Sequence Number: 6663152
• Product Code: FTR
• UDI-Device Identifier: 10888628003767
• UDI-Public: 10888628003767
• Combination Product (Y/N): N
• 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: 2019
• Reporter Type: Manufacturer
• Report Source: Other,Consumer,Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 04/13/2023

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: 10/24/2020
• Device Model Number: MX-410520
• Device Catalogue Number: MX-410520
• Device Lot Number: 2837220
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 03/23/2023
• Initial Report FDA Received Date: 04/13/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 11/24/2015
• 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: 47 YR
• Patient Sex: Female