BEUDAMED
    FDA Adverse Event Injury Summary report: N

    UNKNOWN MENTOR

    MDR report key: 17795384 · Received September 21, 2023

    Report

    Report Number
    1645337-2023-11265
    Event Type
    Injury
    Date Received
    September 21, 2023
    Date of Event
    November 1, 2014
    Manufacturer
    MENTOR TEXAS
    Product Code
    FTR
    PMA / PMN Number
    UNK
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 0

    SINCE THE DEVICE HAS NOT BEEN RETURNED FOR ANALYSIS, NO PRODUCT FAILURE ANALYSIS CAN BE CONDUCTED, AND NO DETERMINATION OF POSSIBLE CONTRIBUTING FACTORS CAN BE MADE. AS SUCH, THE INVESTIGATION WILL BE CLOSED. IF THE COMPLAINT DEVICE IS RECEIVED IN THE FUTURE, THE INVESTIGATION WILL BE REOPENED AND CONDUCTED AS APPROPRIATE. SINCE NO LOT NUMBER WAS PROVIDED, NO MANUFACTURING RECORD EVALUATION COULD BE PERFORMED. REASON FOR DEVICE EXPLANT AND/OR REOPERATION: DEVICE EXTRUSION. MENTOR IS SUBMITTING THIS REPORT PURSUANT TO THE PROVISIONS OF 21 CFR, PART 803. THIS REPORT MAY BE BASED ON INFORMATION WHICH MENTOR HAS NOT BEEN ABLE TO INVESTIGATE OR VERIFY PRIOR TO THE REQUIRED REPORTING DATE. THIS REPORT DOES NOT REFLECT A CONCLUSION BY FDA, MENTOR, OR ITS EMPLOYEES THAT THE REPORT CONSTITUTES AN ADMISSION THAT THE DEVICE, MENTOR, OR ITS EMPLOYEES CAUSED OR CONTRIBUTED TO THE POTENTIAL EVENT DESCRIBED IN THIS REPORT. IF CERTAIN INFORMATION IS UNKNOWN, NOT AVAILABLE OR DOES NOT APPLY, THE SECTION/FIELD OF THE FORM IS LEFT BLANK. MANUFACTURER¿S REFERENCE NUMBER: (B)(4).

    Description of Event or Problem · 0

    IT WAS REPORTED THAT A PATIENT UNDERWENT BREAST PROSTHESIS IMPLANTATION SURGERY WITH TWO UNKNOWN MENTOR IMPLANTS. POST-OPERATIVELY, THE PATIENT SUFFERED BILATERAL IMPLANTS THAT KEPT POPPING THROUGH THE SKIN. AS A RESULT, THE PATIENT UNDERWENT BILATERAL BREAST IMPLANT REMOVAL AND REPLACEMENT SURGERY ON (B)(6) 2015. THE REPLACEMENT DEVICES WERE: (RIGHT) 570CC MENTOR MEMORYSHAPE BREAST IMPLANT CATALOG: 3341507 LOT: 6934920 SN: (B)(6), AND (LEFT) 570CC MENTOR MEMORYSHAPE BREAST IMPLANT CATALOG: 3341507 LOT: 6934920 SN: (B)(6). THIS MEDWATCH FORM IS FOR THE LEFT BREAST PROSTHESIS. THE PRODUCT IS STILL UNKNOWN AND THE COMMON DEVICE NAME AND PROCODE VALUES ARE BEING USED FOR SUBMISSION PURPOSES ONLY. A SUPPLEMENTAL REPORT WILL BE SUBMITTED IF CLARIFYING INFORMATION IS RECEIVED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    524871 UNKNOWN MENTOR PROSTHESIS, BREAST, NONINFLATABLE, INTERNAL, SILICONE GEL-FILLED FTR MENTOR TEXAS

    Patients

    Seq Age Sex Outcome Treatment
    1 43 YR Female Required Intervention