MAUDE Adverse Event Report: ALLERGAN (COSTA RICA) STYLE 133LV TISSUE EXPANDER; EXPANDER, SKIN, INFLATABLE

Model Number	133LV-12
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	10/05/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
A review of the device history record has been completed.No deviations or non-conformances noted.Further information from the reporter regarding event, product, or patient details has been requested.No additional information is available at this time.Device labeling: the following is a list of potential adverse events that may occur with breast implant surgery.The risks include: implant deflation/leakage, additional surgery, capsular contracture, infection, toxic shock syndrome, necrosis, hematoma, seroma, extrusion, breast pain, changes in nipple sensation, changes in breast sensation, dissatisfaction with cosmetic results (wrinkling, folding, displacement, asymmetry, palpability, visibility, ptosis, sloshing), calcific deposits, irritation/inflammation, delayed wound healing, hypertrophic scarring, breast tissue atrophy/chest wall deformity, difficulty/inability in breast feeding, and inability to adequately visualize breast lesions with mammography.In addition to these potential adverse events, there have been concerns with certain systemic diseases.
Event or Problem Description
Healthcare professional reported "while filling the tissue expander it was noticed that there was a 'deflation'." surgery was successfully completed with a back up device.The tissue expander did make patient contact.
Additional Manufacturer Narrative
Device evaluation: visual analysis of the returned device identified: opening, brown particle.Leak test was performed and found opening on anterior side.A microscopic analysis was performed which identified a puncture opening on anterior side, consist in the use of some surgical tool.Based on the device analysis the final assessment is: a puncture opening on anterior due to surgical damage like.
Event or Problem Description
Healthcare professional reported "while filling the tissue expander it was noticed that there was a 'deflation'." surgery was successfully completed with a back up device.The tissue expander did make patient contact.

• Brand Name: STYLE 133LV TISSUE EXPANDER
• Common Device Name: EXPANDER, SKIN, INFLATABLE
• Manufacturer (Section D): ALLERGAN (COSTA RICA); 900 parkway global park; zona franca; CS
• MDR Report Key: 6980859
• Report Number: 9617229-2017-03890
• Device Sequence Number: 16423414
• Product Code: LCJ
• UDI-Device Identifier: 10888628004054
• UDI-Public: (01)10888628004054(10)2703116(11)150206(17)190106
• Combination Product (Y/N): N
• Initial Reporter State: NY
• Initial Reporter Country: US
• PMA/510(K) Number: K862203
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 02/22/2018

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: 01/06/2019
• Device Model Number: 133LV-12
• Device Catalogue Number: 133LV-12
• Device Lot Number: 2703116
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/29/2018
• Initial Date Received by Manufacturer: 10/05/2017
• Supplement Date Received by Manufacturer: 02/02/2018
• Initial Report FDA Received Date: 10/26/2017
• Supplement Report FDA Received Date: 02/22/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 37 YR