MAUDE Adverse Event Report: ALLERGAN (COSTA RICA) Style 168 Saline Filled Breast Implant; prosthesis, breast, inflatable, internal, saline

Catalog Number	168-510
Medical Device Problem Codes	Fluid/Blood Leak (1250); Device Appears to Trigger Rejection (1524)
Health Effect - Clinical Codes	Calcium Deposits/Calcification (1758); Capsular Contracture (1761)
Date of Event	02/01/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
Healthcare professional reported "capsular contracture, baker grade iii¿ and ¿benign calcifications¿.This record is for the right side.Device was explanted.
Additional Manufacturer Narrative
A review of the device history record has been completed.No deviations or non-conformances noted.The event of "calcification and capsular contracture" is a 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: calcification and capsular contracture, baker grade iii.
Event or Problem Description
Healthcare professional reported "capsular contracture, baker grade iii¿ and ¿benign calcifications¿.Healthcare professional later reported "hole in radius (edge)".This record is for the right side.Device was explanted.
Additional Manufacturer Narrative
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 two openings through microscopic assessed as surgical damage.No further actions are required as it is not related to the manufacturing process.¿ calcification: observed calcification on device through visual inspection.No further actions are required as it is not related to the manufacturing process.None of the other observations performed during the device analysis (crease and wear abrasion) are found to be potentially related to the manufacturing process, and, therefore, no further actions are required for these observations.Additional, changed, and/or corrected data: a2, a5, a6, b1, b5, d9, e1, h3, h6.

• Brand Name: Style 168 Saline Filled Breast Implant
• Common Device Name: prosthesis, breast, inflatable, internal, saline
• 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 ; +1(847)936-6324
• MDR Report Key: 25840699
• Report Number: 9617229-2026-13516
• Device Sequence Number: 9477404
• Product Code: FWM
• UDI-Device Identifier: 10888628000889
• UDI-Public: (01)10888628000889(17)070320
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: P990074
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2004
• Device Explanted Year: 2026
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 09/18/2026

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 Expiration Date: 03/20/2007
• Device Catalogue Number: 168-510
• Device Lot Number: 561216
• Was Device Available for Evaluation?: Yes
• Date Returned to Manufacturer: 08/26/2026
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 06/18/2026
• Supplement Date Received by Manufacturer: 09/07/2026
• Initial Report FDA Received Date: 07/16/2026
• Supplement Report FDA Received Date: 09/18/2026
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 05/07/2003
• 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: 59 YR
• Patient Sex: Female
• Patient Weight: 135 LB