inforMED
MalfunctionODU

MICROAIRE ENDOTINE

Received May 20, 2021 · Event occurred Apr 21, 2021

Report 2020601-2021-00002 · MDR key 11855410

Device

Generic name

Endotine Forehead 3.0

Model number

CFD-22202

Catalog number

CFD-22202

Lot number

355991

Product problems

  • Connection Problem
  • Connection Problem

Patient

50 YR

  • Failure of Implant
  • Failure of Implant

Narrative

Additional Manufacturer Narrative

THE DEVICE HISTORY RECORD ASSOCIATED WITH PART # CFD-22202, LOT # 355991 WAS REVIEWED AND THERE WERE NO ANOMALIES IDENTIFIED WITHIN THE MANUFACTURING PROCESS WHICH WOULD RESULT IN THE REPORTED ISSUE. A REVIEW OF THE DEVICE'S COMPLAINT HISTORY HAS REVEALED THAT THIS PRODUCT IS PERFORMING AS EXPECTED, WITH REGARDS TO THE REPORTED FAILURE MODE. A NURSE WITH THE POSTOPERATIVE AREA STATED THAT THE PATIENT WAS BANGING HER HEAD AGAINST THE SIDE RAIL OF THE BED WHEN SHE WAS WAKING UP FROM THE INITIAL SURGERY THEN THIS MAY HAVE BEEN WHEN THE ENDOTINE DISLODGED. THE BROW DESCENT IS A SECONDARY FAILURE OCCURRING AS A RESULT OF LOSS OF FIXATION WITHIN THE POST/HOLE INTERFACE DUE TO PATIENT ACTIVITY.

Description of Event or Problem

ON (B)(6) 2021 THE DOCTOR STATES THAT A (B)(6) YEAR OLD WHITE FEMALE UNDERWENT AN ENDOSCOPIC BROW LIFT WITH LOWER LID BLEPHAROPLASTY AND FAT TRANSPLANT APPROXIMATELY 3 WEEKS AGO. POSTOPERATIVELY, SHE HAD AN ASYMMETRY WITH THE RIGHT SIDE BEING LOWER THAN THE LEFT. SHE HAD THIS PREOPERATIVELY, BUT IT WAS MORE OBVIOUS AND A REVISION SURGERY WAS DISCUSSED TO REENGAGE THE ENDOTINE OR MAKE A NEW FIXATION IN ORDER TO REESTABLISH SYMMETRY OF HER BROW. ON (B)(6) 2021 THE REVISION SURGERY WAS COMPLETED AND THE DOCTOR IDENTIFIED THAT THE INITIAL ENDOTINE IMPLANT WAS DISLODGED FROM THE SURGICAL SITE. ONCE THE DISLODGED IMPLANT WAS REMOVED AND DISCARDED ANOTHER SURGICAL SITE WAS DRILLED AND A NEW ENDOTINE IMPLANT WAS SUCCESSFULLY SEATED AND ADDRESSED THE BROW DESCENT.

Remedial action

  • Replace