MAUDE Adverse Event Report: ALLERGAN (COSTA RICA) STYLE 168 SALINE FILLED BREAST IMPLANT; PROSTHESIS, BREAST, INFLATABLE, INTERNAL, SALINE

Catalog Number	168-420
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	02/11/2019
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.This is a known potential adverse event addressed in the product labeling.
Event or Problem Description
Healthcare professional reported a right side deflation.Device remains implanted.
Event or Problem Description
Device has been explanted.
Additional Manufacturer Narrative
Device evaluation: analysis of the returned device identified: broken plug strap and opening on anterior.Leak test and microscopic analysis was performed which identified: opening striated, opening striated puncture and delamination on plug strap (<75% partial separation).The fill test inspection was performed, the result is no blockage.Based on the device analysis the final assessment is: a striated opening due to surgical damage consist in the use of some surgical tool.A striated punctured due to surgical damage like consist in the use of some surgical tool.A sharp broken on plug strap due to an unidentified (tear) opening.A delamination total of the valve (cohesive failure).Reason for reoperation: deflation.
Event or Problem Description
Healthcare professional reported a right side deflation.Device has been explanted.

• 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; CS
• MDR Report Key: 8423134
• Report Number: 9617229-2019-01583
• Device Sequence Number: 11325094
• Product Code: FWM
• UDI-Device Identifier: 10888628000858
• UDI-Public: 10888628000858
• Combination Product (Y/N): N
• Initial Reporter State: FL
• PMA/510(K) Number: P990074
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 06/03/2019

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: 05/12/2021
• Device Catalogue Number: 168-420
• Device Lot Number: 3064091
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/09/2019
• Initial Date Received by Manufacturer: 02/25/2019
• Supplement Date Received by Manufacturer: 03/22/2019; 05/06/2019
• Initial Report FDA Received Date: 03/14/2019
• Supplement Report FDA Received Date: 04/15/2019; 06/03/2019
• 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: 48 YR