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-410775
Medical Device Problem Code	Migration (4003)
Health Effect - Clinical Code	Seroma (2069)
Date of Event	01/11/2021
Type of Reportable Event	Serious Injury
Event or Problem Description
Patient reported left side "elevated liver enzymes", "joint pain", "brain fog", "hair loss", "fluid around implant", "silicone poisoning" and exchange from textured to smooth due to concern with the product.Device remains implanted.
Additional Manufacturer Narrative
A review of the device history record has been completed.No deviations or non-conformances noted.The event of seroma-late and silicone migration are physiological complication and analysis of the device generally does not assist allergan in determining a probable cause for this event.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: seroma - late and silicone migration.
Event or Problem Description
Patient reported left side "elevated liver enzymes", "joint pain", "brain fog", "hair loss", "fluid around implant", "silicone poisoning" and exchange from textured to smooth due to concern with the product.Device remains implanted.
Additional Manufacturer Narrative
Device evaluation: a review of the device noted, deformation.
Event or Problem Description
Patient reported, left side "fluid around implant", "silicone poisoning".And exchange from textured to smooth, due to concern with the product.Healthcare professional, later confirmed.Patient also reported, "joint pain", "brain fog", "hair loss", "elevated liver enzymes".Which, have been deemed not device related.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: 17083646
• Report Number: 9617229-2023-09520
• Device Sequence Number: 20398311
• Product Code: FTR
• UDI-Device Identifier: 10888628003040
• UDI-Public: 10888628003040
• 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: 2017
• Device Explanted Year: 2023
• Reporter Type: Manufacturer
• Report Source: Consumer,Health Professional
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 12/05/2023

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: 08/13/2022
• Device Model Number: FX-410775
• Device Catalogue Number: FX-410775
• Device Lot Number: 3106121
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 05/18/2023
• Supplement Date Received by Manufacturer: 09/29/2023; 11/13/2023
• Initial Report FDA Received Date: 06/07/2023
• Supplement Report FDA Received Date: 10/20/2023; 12/05/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 09/13/2017
• 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: 52 YR
• Patient Sex: Female
• Patient Weight: 103 KG