MAUDE Adverse Event Report: ALLERGAN (COSTA RICA) NATRELLE TE SMOOTH 133S-MV-15-T; EXPANDER, SKIN, INFLATABLE

Catalog Number	133S-MV-15-T
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	04/15/2025
Type of Reportable Event	Serious Injury
Event or Problem Description
Healthcare professional reported "ruptured at the patch".This record is for the unknown side.The device has been explanted and replaced.
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.Reason for reoperation: rupture.
Event or Problem Description
Healthcare professional reported "ruptured at the patch".This record is for the unknown side.The device has been explanted and replaced.
Additional Manufacturer Narrative
Additional, changed, and/or corrected data: a2, a4, a5, a6, b3.
Event or Problem Description
Healthcare professional reported "ruptured at the patch".This record is for the unknown side.The device has been explanted and replaced.
Additional Manufacturer Narrative
Additional, changed, and/or corrected data: d9, h3, h6.Device evaluation: per the analysis performed, the assessments of the complaints and any potential manufacturing issue are displayed along with any further actions required: ¿deflation: observed an opening through microscopic inspection assessed as unidentified (tear) opening and observed delamination of the patch and through microscopic inspection assessed as adhesive failure.No further actions are required as it is not related to the manufacturing process.None of the other observations performed during the device analysis creases, wear abrasion, broken suture tabs and missing of the suture tabs are found to be potentially related to the manufacturing process, and, therefore, no further actions are required for these observations.
Event or Problem Description
Healthcare professional reported "ruptured at the patch".This record is for the unknown side.The device has been explanted.
Additional Manufacturer Narrative
Additional, changed, and/or corrected data: d1, d4, g4, h4, h.6, h11.A review of the device history record has been completed.No deviations or non-conformances noted.
Additional Manufacturer Narrative
Additional, changed, and/or corrected data: b5, h6.
Event or Problem Description
Affected side is right.

• Brand Name: NATRELLE TE SMOOTH 133S-MV-15-T
• Common Device Name: EXPANDER, SKIN, INFLATABLE
• 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: 23771936
• Report Number: 9617229-2025-21545
• Device Sequence Number: 13402400
• Product Code: LCJ
• UDI-Device Identifier: 10888628043893
• UDI-Public: (01)10888628043893(10)3671597(11)230131(17)271231
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K182054
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2025
• Reporter Type: Manufacturer
• Report Source: Other,Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup,Followup,Followup
• Report Date (Section B): 03/19/2026

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 Catalogue Number: 133S-MV-15-T
• Device Lot Number: 3671597
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 11/25/2025
• Supplement Date Received by Manufacturer: 01/04/2026; 02/02/2026; 02/23/2026; 02/18/2026
• Initial Report FDA Received Date: 12/10/2025
• Supplement Report FDA Received Date: 01/13/2026; 02/04/2026; 03/10/2026; 03/19/2026
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 01/31/2023
• 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: 50 YR
• Patient Sex: Female
• Patient Weight: 87 KG
• Patient Ethnicity: Hispanic
• Patient Race: White