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

Model Number	TRX-400
Medical Device Problem Code	Patient-Device Incompatibility (2682)
Health Effect - Clinical Code	Capsular Contracture (1761)
Date of Event	12/19/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
A review of the device history record has been initiated.If any new, changed or corrected information is noted, a supplemental medwatch will be submitted.The event of 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: capsular contracture, baker grade iv.
Event or Problem Description
Healthcare professional reported left side capsular contracture, baker grade iv.Device remains implanted.
Event or Problem Description
Patient additionally reported ""problems with my hands and arms", "swelling", "redness", "pallor", "change in temperature", "severe pain", "severe pain in neck", "extreme vascular and neuro problems in my upper extremities", "unable to use my hands", "several acute bilateral posterior rib fractures without trauma or incident", "rib fractures" and "developed severe rib pain." these events are not device related.Patient also reported "developed severe back and chest pain." device has been explanted.
Event or Problem Description
Healthcare professional reported left side capsular contracture, baker grade iv.Patient additionally reported ""problems with my hands and arms", "swelling", "redness", "pallor", "change in temperature", "severe pain", "severe pain in neck", "extreme vascular and neuro problems in my upper extremities", "unable to use my hands", "several acute bilateral posterior rib fractures without trauma or incident", "rib fractures" and "developed severe rib pain." these events are not device related.Patient also reported "developed severe back and chest pain." device has been explanted.
Additional Manufacturer Narrative
In response to fda report number: mw 5092449.A review of the device history record has been completed.No deviations or non-conformances noted.

• Brand Name: INSPIRA TEXTURED 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; CS
• MDR Report Key: 9597698
• Report Number: 9617229-2019-23318
• Device Sequence Number: 16769068
• Product Code: FTR
• UDI-Device Identifier: 10888628008502
• UDI-Public: 10888628008502
• Combination Product (Y/N): N
• Initial Reporter State: CA
• PMA/510(K) Number: P020056
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: consumer,health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 11/25/2020

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: 02/16/2021
• Device Model Number: TRX-400
• Device Catalogue Number: TRX-400
• Device Lot Number: 2885032
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 12/20/2019
• Supplement Date Received by Manufacturer: 09/21/2020; 10/29/2020
• Initial Report FDA Received Date: 01/16/2020
• Supplement Report FDA Received Date: 10/21/2020; 11/25/2020
• 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: 53 YR