MAUDE Adverse Event Report: ALLERGAN (COSTA RICA) STYLE 110 SILICONE GEL FILLED BREAST IMPLANT; PROSTHESIS, BREAST, NONINFLATABLE, INTERNAL, SILICONE GEL-FILLED

Catalog Number	110-210
Medical Device Problem Code	Material Rupture (1546)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	11/16/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
Healthcare professional reported a left side rupture.Device explanted.
Additional Manufacturer Narrative
Further information from the reporter regarding event, product, or patient details has been requested.No additional information is available at this time.A review of the device history record has been completed.No deviations or non-conformance's noted.Reason for reoperation: rupture.
Additional Manufacturer Narrative
Photo evaluation: visual analysis of the photographs identified: ¿ rupture: observed but cannot perform an assessment of the opening as no microscopic analysis can be performed.No additional observations.No further actions are required as no manufacturing issues are observed.Additional, changed, and/or corrected data: h6.
Event or Problem Description
Healthcare professional reported a left side rupture.Device explanted.
Additional Manufacturer Narrative
Lab analysis: based on the product analysis performed, the assessments of the complaint codes are: ¿ rupture: observed broken device assessed as unidentified (tear) opening as per the investigation procedure observed and none of the observations are found to be potentially related to the manufacturing process, no further actions are required.Additional, changed, and/or corrected data: b1, d9, h3, h6.
Event or Problem Description
Healthcare professional reported a left side rupture.Device explanted.
Additional Manufacturer Narrative
Additional, changed, and/or corrected data: b3, b6, d4, d6a, h6.
Event or Problem Description
Healthcare professional reported a left side rupture.Device explanted.

• Brand Name: STYLE 110 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; la aurora de heredia ; CS
• Manufacturer (Section G): ALLERGAN (COSTA RICA); 900 parkway global park; zona franca; la aurora de heredia ; CS
• Manufacturer Contact: terry ingram ; 2525 dupont drive; irvine, CA 92612 ; 8479366324
• MDR Report Key: 21323907
• Report Number: 9617229-2025-02071
• Device Sequence Number: 7917576
• Product Code: FTR
• UDI-Device Identifier: 10888628002197
• UDI-Public: (01)10888628002197(10)2889634(11)160329(17)210228
• Combination Product (Y/N): N
• Initial Reporter Country: KS
• PMA/510(K) Number: P020056
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2024
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,Company Representative,Distributor
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup,Followup
• Report Date (Section B): 04/07/2025

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?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 02/28/2021
• Device Catalogue Number: 110-210
• Device Lot Number: 2889634
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/16/2025
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 01/16/2025
• Supplement Date Received by Manufacturer: 02/07/2025; 03/12/2025; 07/14/2025
• Initial Report FDA Received Date: 02/06/2025
• Supplement Report FDA Received Date: 03/04/2025; 04/07/2025; 08/08/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 03/29/2016
• 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: 74 YR
• Patient Sex: Female
• Patient Race: Asian