MAUDE Adverse Event Report: MENTOR TEXAS MENTOR CPX4 WITH SUTURE TABS, MED HEIGHT, SMOOTH; EXPANDER, SKIN, INFLATABLE

Catalog Number	3509215
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Autoimmune Disorder (1732); Hematoma (1884); Deformity/ Disfigurement (2360)
Date of Event	01/28/2021
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that a female patient who underwent breast reconstruction revision with a mentor 650cc medium height smooth cpx4 with suture tabs experienced left sided asymmetry and subsequent left sided hematoma post procedure.As a result, an explant was performed on (b)(6), 2021.This event is associated with the athena clinical trial.
Additional Manufacturer Narrative
Since the device has not been returned for analysis, no product failure analysis can be conducted, and no determination of possible contributing factors can be made.As such, the investigation will be closed.If the complaint device is received in the future, the investigation will be reopened and conducted as appropriate.A manufacturing record evaluation (mre) was performed, and no anomalies were found related to this complaint.In addition, the mre verifies that the device was manufactured in accordance with documented specification and procedures.Reason for device explant and/or reoperation: asymmetry/hematoma.Mentor is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which mentor has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, mentor, or its employees that the report constitutes an admission that the device, mentor, or its employees caused or contributed to the potential event described in this report.If certain information is unknown, not available or does not apply, the section/field of the form is left blank.Manufacturer¿s reference number: (b)(4).
Additional Manufacturer Narrative
Additional information was received on april 9, 2025.In addition to the issues reported previously, the patient also experienced and autoimmune diagnosis.The following was noted: sjogren's syndrome, esophageal varices, with bleeding, left breast blisters, dry mouth, thrombocytopenia, dry eyes, and liver fibrosis were noted symptoms.Reason for device explant and/or reoperation: asymmetry/hematoma/autoimmune disorder manufacturer¿s reference number: (b)(4).

• Brand Name: MENTOR CPX4 WITH SUTURE TABS, MED HEIGHT, SMOOTH
• Common Device Name: EXPANDER, SKIN, INFLATABLE
• Manufacturer (Section D): MENTOR TEXAS; 3041 skyway circle north; irving TX 75038
• Manufacturer (Section G): MENTOR TEXAS; 3041 skyway circle north; irving TX 75038
• Manufacturer Contact: kate karberg ; 3041 skyway circle north; irving, TX 75038 ; 3035526892
• MDR Report Key: 17652001
• Report Number: 1645337-2023-10189
• Device Sequence Number: 12345229
• Product Code: LCJ
• UDI-Device Identifier: 00081317026686
• UDI-Public: 00081317026686
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K182335
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Study
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup

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: 11/03/2023
• Device Catalogue Number: 3509215
• Device Lot Number: 9391062
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 08/15/2023
• Supplement Date Received by Manufacturer: 04/09/2025
• Initial Report FDA Received Date: 08/30/2023
• Supplement Report FDA Received Date: 05/07/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 10/31/2019
• 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: 70 YR
• Patient Sex: Female
• Patient Weight: 102 KG
• Patient Ethnicity: Non Hispanic
• Patient Race: White