Académique Documents
Professionnel Documents
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Technical informations
2012 edition
0459
Introduction Raw materials used by ceReplas............................................................... 3 Technical characteristics of ceRefoRm implants..................................... 3 controls performed on ceRefoRm implants............................................. 4 certification and ec marking of ceRefoRm implants............................... 5 evaluation of clinical datas............................................................................ 5 prospective clinical follow-up for ceRefoRm implants............................. 8 monitoring post implantation ceRefoRm implants on the market............. 12 ceReplas guarantee................................................................................... 14 civil liability of ceReplas............................................................................. 14 appendix 1 ...................................................................................................... 16 mechanical tests and biocompatibility trials performed on ceRefoRm implants appendix 2 ................................................................................................... 19 fda certificates for the raw materials for ceRefoRm implants appendix 3 ................................................................................................... 24 certificates for ceReplas and ceRefoRm implants appendix 4 ................................................................................................... 38 civil liability insurance certificate Useful links
/// introduction
for several years breast implants pre-filled with silicone gel have been very widely used. The rules governing the manufacturing process and usage of breast implants and more generally those which apply to all medical devices, have been strengthened to ensure safe and effective devices are offered to the patient. The strict regulations have lead to improved manufacturing process and the quality of the medical devices. In the interest of transparency ceReplas would like to provide you with more information on the technical characteristics of its ceRefoRm range of breast implants pre-filled with silicone gel. our ability to offer high quality implants at a competitive price is a direct result of the choices ceReplas made in its manufacturing process. These revolutionary manufacturing choices have, of course, required significant investment by ceReplas but the results are a superior product at affordable price to clients. The state of the art design and manufacturing facility employs the latest technology available and in some instance very unique and exclusive to ceRefoRm breast implants. The robotics used in creating implant envelopes is just one of such examples, ceReplas has also devised a very unique envelope surface texturing process where texture is achieved by a negative replica of the mould surface, ceReplas uses autogenous welding of the patch and performs numerous controls on each implant. This enables us to obtain repeatability, reliability, and faultless, 100% pure silicone implant of excellent quality without any contaminants. We have complete control of our manufacturing process and raw materials and therefore of the finished product. ceRefoRm confirms the product standard and quality with a battery of about thirty standardised tests for biocompatibility and mechanical performance as well as by physical, chemical and biological tests.
Patch
This process also makes it possible to obtained managed thicknesses with no discontinuity or fragility (particularly around the equator). The patch for ceRefoRm implants also contains a silicone barrier layer in order to limit the phenomenon of the silicone perspiration at any point in the implants. for better patch resistance, the patch is over-molded to the envelope, making it possible to obtain autogenous welding which is more effective mechanically than simple bonding. ceRefoRm implants are made of a medical grade cohesive cross-linked gel reducing any risk of excessive inflammation if the envelope should rupture. The cohesiveness of the gel also ensures that the gel does not spread into the breast tissue if the envelope breaks. The implant is filled through a "filling channel along the patch thus making it possible to avoid weakening the patch by perforating it. The mechanical performance of the implant and the compatibility between the gel and the envelope are also constantly monitored by the performance of stability studies and regular quality controls. This enables us to state that the gel we use does not weaken our envelope. Texturing of ceRefoRm breast implants is performed directly on the mould and not by the addition of a texturing agent (such as salt). This avoids any weakening of the envelope by the texturing agent. The breast implants are sterilised with ethylene oxide and are single use.
Fatigue test; Impact test; Cohesiveness and gel penetration; Fatigue test; Characterisation of the silicone ; Measurement of the gel perspiration through the envelope ; Endotoxins and bioloads. The implants are manufactured in a clean room, Type Iso 7 (or class 10,000 ) in which the atmospheric parameters (temperature ; pressure and hygrometry) are controlled. In addition, 25 weekly microbiological controls are carried out to check the cleanliness of our working environment, which is validated every year by an independent organisation.
This evaluation was performed in two stages. The initial report summarised the data for 100% silicone breast implants, including all generations up to 2006 ; its amendment focuses on third generation breast implants (publications dating from 2006 onwards). an update of the bibliographical data will be made during the 2nd half of 2012. as a reminder, the third generation implants evolved after the moratorium on breast implants, which until then were filled with silicone oils or more liquid gels and which presented a very high perspiration gel bleed rate through the envelope. The manufacturers, therefore, have designed more effective implants, said to be third generation or shape memory , with a very cohesive silicone gel and an envelope that greatly limits perspiration (incorporation of a layer known as a Barrier layer). ceRefoRm implants come into this category. The statistics gathered in the amendment are thus more relevant, but it must be stressed that the follow-up for third generation implants is not yet sufficient to obtain long-term data from this.
Adverse effects
Implant type
Operation indication
Date of occurencee
Extrem values
All Capsule contracture All Primary augmentation revision augmentation Primary reconstruction revision reconstruction All All All All All All All Augmentation revision All
rupture Infection Pain Hematoma / Seroma Wound healing problem Incorrect position / Displacement Asymmetry folds / Undulations
0.8 to 7.5% 1.9 to 18.9% 20.6% 14.8 to 20.5% 0.8 to 14.8% 2.2 to 20.5% 5.9 to 18.9% 6.1 to 16.3% 0.0 to 7.7% 2.3 to 9.3% 8.0% 0.0 to 7.4% 1.1 to 9.6% 1.0 to 9.3% 1.5 to 6.4% 1.4 to 8.5% 0.8 to 22.9% 0.8 to 3.7% 6.7 to 22.9% 0.5 to 10.2%
Performance of third generation implants The complication rates obtained in the amendment were mostly lower than those in the initial report. This rate reduction is explained by better quality implants and by better managed surgical technique. The complications for which a rate increase is observed are complications that are better detected and better supervised today. Critical analysis of this data The number of studies used to gather the data for the amendment remains low. This is explained by the fact that the research studies are studies published from 2006 onwards in order to select articles dealing with 3rd generation breast implants, equivalent to those from ceReplas. as breast implants have been closely studied due to their history, the new publications consider very specific cases and are not therefore useful for our amendment.
The maximum prevalence in the initial bibliographical study and the amendment are summarised in the table below :
Adverse effects
Type dimplant
Operation indication
Maximum prevalence Date (bibliographical study) All of occurence generations of implants included
Capsular contracture
All
All
rupture
All
All
2 years 3 years 5 years 6 years 10 years 3 years 6 years 8 years 10 years 11 years -
9% 67.1% 10% 40% 7.7% 53% 11.8% 3.9% 11.8% 61% 8% 2.8%
7.5% 18.9% 20.6% 20.5% 7.7% 9.3% 8% 7.4% 9.6% 9.3% 8.5% 6.7% 11% 10.2% 8.4%
Healing problem
a new analysis of the bibliographical data will be performed during the 2nd half of 2012 in order to obtain even more accurate data. This bibliographical analysis serves as a reference and is, of course, completed by a specific clinical follow-up involving 210 patients with ceRefoRm implants, which began in January 2009, and by increased market surveillance. These subjects are dealt with in the following chapters.
problems with nipple sensitivity ; problems with breast sensitivity ; displacement of the implant ; poor wound healing (hypertrophic or cheloid scar) ; haematoma ; modification of breast consistency, a lump in the breast ; modification of breast volume or breast shape, ptosis ; pain in the breast ; change in the appearance of the breast, skin folds ; a discharge or a seroma ; a local (around the implantation area) or general infection ; asymmetry ; inflammation ; an autoimmune disease ; breastfeeding difficulties ; local complications ; any other complication linked to the implant, to be specified by the investigator. The secondary objectives will involve evaluating and assessing patient satisfaction and well-being as well as the satisfaction of the investigator with the aesthetics of the result obtained. > Study population In order to define the desired population in the context of this follow-up, inclusion and non-inclusion criteria have been defined so that, the study population represents, the best way possible all women that may contemplate having breast implants. Main inclusion criteria the patient is female ; the patient is over the age of 18 and under the age of 60 ; the patient will receive at least one CEREFORM breast implant during a breast reconstruction following a mastectomy or during cosmetic breast surgery. Main non-inclusion criteria the patient refuses to sign the informed consent form ; the patient presents with evolving (unstabilised) breast cancer. > Method of observation and investigation selected Evaluation by the investigator The evaluation of the safety and performance of ceRefoRm implants by the investigator is based on the evaluation of the main variables, which are the rate of retractile capsular contracture and the rupture rate. Retractile capsular contracture capsular contractures are evaluated using the Baker classification as reference.
Rupture / Deflation of the implant If a rupture is suspected, the surgeon may need to use medical imaging to confirm / overturn the diagnosis. Evaluation by the patient The patient participates fully in the evaluation of the efficacy of ceRefoRm implants. To do this, the self-assessment questionnaire will be given to the patient before the insertion of the implant, during the inclusion consultation (cinc) and also during the consultation 4 months after implantation (c4m) in order to evaluate her satisfaction and the changes in her quality of life. > Origin and nature of the personal information collected No complete personal information is required for this follow-up. only the two first letters of the surname and first name will be used. all this information is necessary for the traceability of data. all this information will be collected by the investigator after the patient has agreed to participate in this follow-up. > Duration and method of follow-up It is an observational, non-interventional, non-comparative, multi-centre study after placing the device on the market, observing a group of patients with ceRefoRm implants in the context of a breast augmentation or reconstruction. The total duration of this observational study is 10 years, with an inclusion duration of 4 years. This study will be performed by means of several follow-up consultations: 1 inclusion consultation the week before the operation, 3 consultations during the first year after implantation, and 1 annual control consultation during the following 9 years. The patients will be included in 20 centres. Inclusion frequency is 1 patient per centre per month during the inclusion period (4 years). The number of patients to be included is 30 with a maximum of 50 patients per centre. > Data analysis method Analysis factors an ITT analysis will be used. The other analysis factors are: an analysis per implant, per patient, per type of indication, per type of reconstruction, a global analysis of the population by evaluation criterion, a global analysis and by clinical evaluation criterion group. Analysis criteria a global analysis for each group of different complication rates based on the Kaplan meier method will be performed. a presentation of the rate of complications with their confidence interval at 95% will be carried out. > Justification of the number of patients To evaluate the main objective, we define the four main evaluation criteria (studied variables) :
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the capsular contracture rate ; the post-operative rupture rate ; the rate of implant rotation (anatomical implants) ; the rate of systemic diseases. The size of the sample is determined by the formula : n = t. p.(1-p) e
With : n = sample size, e = margin of error, then you set e=5%, t = the margin coefficient deducted from the confidence level. If a result presented in the form of a confidence interval at 95% is required, then t = 1.96 The term p(1-p) varies between the values 0 and 0.25. If an upper bound of the sample size is required, the maximum value of p(1-p) is taken, i.e. 0.25, corresponding to p = 0.5 (e.g. the appearance of a rupture occurs in one in two cases at the end of 10 years the most unfavourable case. If a finer approach which minimises the error on the evaluation of size is required, the average value is taken, i.e. 0.175 which corresponds to p = 0.226. p(1-p) = 0.226*(1-0.226) = 0.1749 is set.
from it you deduct n = 1.96 x 0,1749 / 0,05 = 268,8 ~ 269 patients after a decision by the ccTIRs*, the number of patients has been reduced to 210.
> Intermediate results of the follow-up To date, 137 patients have been included, of whom 124 patients have undergone operations. The inclusion period will end in october 2013. out of these 124 operated patients, 116 came for their consultation at 1 month, 77 at 4 months and 32 at 1 year. The complications encountered with ceRefoRm breast implants were minimal.The most significant complications were : At 1 month : - a stage 3 contracture in 1 patient (0.9%) - an infection in 2 patients (1.8%), including one due to incorrect placement of the Redon drain - a seroma in 2 patients (1.8%) At 4 months : - a stage 3 contracture in 1 patient (1.4%). This contracture was combined with a seroma and seemed to be due to an intolerance to the analgesics - a rotation in 1 patient (1.6%) - a fold in 1 patient (1.6%) At 1 year : no complications were reported No cases of rupture have been shown. patient satisfaction at 4 months is excellent because 100.0% of patients answering the questionnaire were satisfied with the results.
* (french advisory committee on Information processing in material Research in the field of Health)
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> Market monitoring This is possible through feedback from clients from increased market monitoring both through the sales force in the field and government agencies. client feedback sources are: client claims made to telephone exchange operators ; analysis of clinical complications observed with our implants ; analysis of product returns ; materials vigilance declarations relating to our products and competitor products ; reports from marketing managers ; information gathered directly from the engineers and the Quality Department.
> Clinical complications observed on 31/12/11, 261 clinical complications have been observed in a total of 151 187 implants supplied, i.e. 0.17%. These complications are summarised in the table below:
Number of observed complications (31/12/11)
80 70 60 50 40 30 20 10 0 74 37 51 39 19 23 15
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In the majority of cases, gel fractures are detected at implantation. The implants are exchanged immediately and this does not cause any consequences for the patient.
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When the integrity of the envelope is in question, we ask for the implant to be returned to us for investigation, in order to determine whether it can be proven that the implant is at fault.Ruptures of the envelope that we have observed and analyzed are all linked to the implant coming into contact with hard objects. No ruptures linked to implant wear have been demonstrated.
Investigation procedure carried out on each returned implant 1- Traceability of raw materials using the production monitoring software during this stage, we routinely check the material batch numbers and the quality controls performed on the implant under consideration. even though this step is performed when the batches are released on return from sterilisation, it is performed again to ensure that the implant has been manufactured in compliance with our manufacturing processes. 2- microscopic observations if the implant has ruptured The shape, size and depth of the lesion on the envelope routinely shows us if the implant envelope has been weakened by coming into contact with a sharp or hard object as it was implanted. 3- Registration of the claim with the Quality System > Materials vigilance declarations In 2011, eight materials vigilance declarations concerning our breast implants were made by surgeons to afssaps. 1- The complication concerns a gel fracture detected at implantation (January 2011). 2- The complication concerns a rupture of the implant envelope after being implanted for less than a year. after investigation on our part, it proved that the rupture was linked to the use of surgical instruments during the operation. 3- an erroneous declaration concerning a pIp brand breast implant (february 2011). 4 & 5- The complication concern gel fracture detected at implantation (april 2011). 6- The complication concerns a suspicion of self-mutilation with injection of liquid and gas into the interior of the prosthesis (september 2011). 7- The complication concerns a suspicion of rupture, not confirmed on explantation (November 2011). 8- The complication concerns a cohesiveness problem not checked yet by our services (december 2011).
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In 2011, ceReplas made 3 materials vigilance notifications : 1- one complication concerns an implant rotation which led to explantation (November 2011); 2- one complication concerns a problem of folds leading to explantation (december 2011); 3- one complication concerns a rupture of the implant envelope after being implanted for 7 months. after investigation on our part, it proved that the rupture was linked to the use of surgical instruments during the operation (december 2011). > Evolutions / Modifications to the range The analysis of client feedback also enables us to adapt our products to the expectations of surgeons, within the regulatory framework. any modification to the ceRefoRm range and the procedure is only made after analysis, management and control of possible new risks which could appear. It is within this approach that the various evolutions and modifications to the range (addition of a reference ; addition of identification marks on anatomical implants ; improvement of the differentiation between ceRefoRm implants, the pre-filled sizers and the samples) were made. lNe/Gmed are notified of significant modifications so that they may be evaluated within the framework of ce marking before being implemented.
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Driven by a stated, constant desire to develop and perfect the quality of the products and services it offers you, CEREPLAS is implementing the necessary means to meet your requirements in the best possible way. We remain at your disposal to answer any possible remarks or questions at the following address: questions@cereplas.com
To illustrate our commitment to excellence we can arrange for you to visit our manufacturing facility on request.
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Appendix 1
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ENVELOPMENT
Nf eN Iso 14607 Nf eN Iso 14607 Nf eN Iso 14607 Nf eN Iso 14607 Nf eN Iso 14607 Resistance of the bonding following 300% stretching for 10 seconds 24.4 kN/m (average value calculated from implants of competitors) < 10% 17,3N (average value calculated from implants of competitors) 21.5N 4.22% 37.3 kN/m Hold oK - Implant intact > 450% 869%
lengthening
Rupture force
Remanence to traction
Resistance to tearing
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RESISTANCE TO FATIGUE Nf eN Iso 14607 The implant must remain intact Hold oK - Implant intact
IMPACT TEST Nf eN Iso 14607 The implant must remain intact Hold oK - Implant intact
DIFFUSION TEST Nf eN Iso 14607 No specific requirement compliant with our specifications
STATIC RUPTURE TEST Nf eN Iso 14607 No specific requirement compliant with our specifications
Types of test
Standards applicable
pyrogenicity test
cytotoxicity test
Nf eN Iso 10993-5
Haemocompatibility test: haemolysis test on human blood Haemocompatibility test: complement activation test on human plasma micronucleus test
Nf eN Iso 10993-4
Nf eN Iso 10993-4
Nf eN Iso 10993-3
Nf eN Iso 10993-3
Nf eN Iso 10993-3
Nf eN Iso 10993-11
Irritation test
Nf eN Iso 10993-10
Nf eN Iso 10993-10
chronic toxicity and local tolerance test (implantation) Toxicity test on reproduction: prenatal evaluation Toxicity test on reproduction: evaluation on the first generation
Nf eN Iso 10993-3
Nf eN Iso 10993-3
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Appendix 2
19
20
21
22
23
Appendix 3
24
25
26
27
28
29
30
31
32
33
34
35
36
37
Appendix 4
38
39
40
CEREPLAS
chirurgie esthtique
t : +33(0)3 27 83 69 57 f : +33(0)3 27 83 70 42
www.cereplas.com info@cereplas.com
l10002.3-aN - 02 / 2012