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1. Introduction

Objective The Health Sciences Authority (HSA) is issuing these guidelines to provide clarity on the types of *devices intended for modification of appearance or anatomy that are regulated as medical devices, as well as the regulatory approach and regulatory requirements for these medical devices. The guidelines reflect HSA’s current policy stance and practice, and should not be misconstrued as a new regulatory control on devices intended for modification of appearance or anatomy. * For the purpose of this guideline, devices intended for modification of appearance or anatomy refers to devices intended for aesthetic-related purposes •Devices intended for modification of appearance or anatomy include any instrument, apparatus, implement, machine or appliance intended for use on humans, for restoring, improving or modifying physical appearance. Some examples include: – treatment of wrinkles – improving skin texture – skin rejuvenation – body contouring – hair removal •As a general rule, if the device is intended by the product owner for medical andfor modification of appearance or anatomy, the device will be classified as a medical device and will be subjected to medical device regulatory controls by HSA. •There are devices which are intended by the product owner solelyfor modification of appearance or anatomy. Based on surveillance data, there have not been serious adverse events associated with the majority of such products. Background •There are also other existing regulatory oversight currently in place locally on some of these products and their use. For e.g. Singapore Medical Council (SMC) published Guidelines on Aesthetic Practices for Doctors, which lists the allowed aesthetic procedures, premises and training requirements to conduct aesthetic procedures for doctors National Environment Agency (NEA) imposes licensing requirements for individuals or facilities handling ionizing/non-ionizing radiation emitting equipment under the Radiation Protection Act Background •A review of serious adverse events reported globally on similar devices was performed (refer to Table 1) Background Table1. Devicetypesandreportedseriousadverseevents Device TypesExamples of Reported SeriousAdverse Events Glutealimplants, breast implants Rupture, capsular contracture (scar tissues that forms around the implant and squeeze the implant), infection Collagen/ hyaluronic dermal fillers, lip fillers Injection sitenecrosis, nodules, allergic reaction Lipoplasty/ liposuctionequipmentInfection, pulmonaryembolism, visceral perforation Scope This document applies to devices intended by the product owner solely for *modification of appearance or anatomy. * For the purpose of this guideline, devices intended for modification of appearance or anatomy refer to devices intended for aesthetic-related purposes Definitions PRODUCT OWNER (as stated in the Medical Device Regulations): in relation to a health product, is defined as a person who — supplies the health product under his own name, or under any trade mark, design, trade name or other name or mark owned or controlled by him; and is responsible for designing, manufacturing, assembling, processing, labelling, packaging, refurbishing or modifying the health product, or for assigning to it a purpose, whether those tasks are performed by him or on his behalf. DEVICES FOR MODIFICATION OF APPEARANCE OR ANATOMY (aesthetic- related purposes): any instrument, apparatus, implement, machine or appliance intended for use on humans, for restoring, improving or modifying physical appearance and/or anatomy.

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2. Categorisation of Devices Intended for Modification of Appearance or Anatomy as Medical Devices

APPEARANCE OR ANATOMY AS MEDICAL DEVICES Risk-based approach •HSA will adopt a risk based approach and will subject only a positive list of high risk devices intended solely for modification of appearance or anatomy to the medical device regulatory controls •The following positive list is drawn up based on the global post-market surveillance data and a comparison of risk presented by some of these products to that of other medical devices: Annex A: Positive list of high riskdevices intended for modification of appearance or anatomyto be regulated as medical devices: i.any implant for the modification or fixation of any body part ii.any injectable dermal filler or mucous membrane filler iii.any instrument, apparatus, implement, machine or appliance intended to be used for the removal or degradation of fat by invasive means APPEARANCE OR ANATOMY AS MEDICAL DEVICES Risk-based approach •The Annex A positive list may be expanded in the future as and when new risks are identified. New risks or hazards that are posed by the advent of new technology, new application or use of existing technology, and new risks surfacing from wide-spread use will be factors that will be considered when deciding to update the positive list in the future. •The intended use of devices for modification of appearance or anatomy will determine whether it will be regulated as a medical device. The intended use is reflected on the specifications, instructions and information provided by the product owner of the product. •In order to determine whether a product intended for modification of appearance or anatomyis a medical device, please refer to Flowchart 1. Yes APPEARANCE OR ANATOMY AS MEDICAL DEVICES Risk-based approach Is the product also used for a medical purpose ? Is the product solelyfor restoring, improving or modifying physical appearance and/or anatomy? Is the product type listed in the Annex A: positive list of high risk devicesintended for modification of appearance or anatomy? No Examples: •Dermal fillers for treatment of nasolabial folds •Implants for breast augmentation (non-medical) and reconstruction of the breasts after mastectomy (medical) The product is regulated as a Medical Device Yes The product is NOT a Medical Device Flowchart 1: Is the device intended for modification of appearance or anatomy regulated as a Medical Device? No No Yes

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3. Regulatory Controls of Devices for Modification of Appearance or Anatomy as Medical Devices

Medical devices for modification of appearance or anatomy (Annex A) are subjected to the following medical device regulatory controls: • Product Registration; • Dealer’s licence requirements; • Post-market obligations Product Registration •In order to supply medical devicesfor modification of appearance or anatomy (Annex A)in Singapore, the company is required to obtain marketing clearance for the device from HSA via Product Registration before supply of the devices in Singapore. •As with all other medical devices, medical devices for modification of appearance or anatomy (Annex A) are classified into different risk classification as per GN-13: Guidance on the Risk Classification of General Medical Devices, depending on the nature of the device and its intended functions. •The submission requirements and process, depending on the risk class of the medical devices for modification of appearance or anatomy (Annex A), will follow as per GN-15: Guidance on Medical Device Product Registration. Product Registration •Some key safety concerns specific to medical devices for modification of appearance or anatomy (Annex A) have been identified (refer to Table 2) that will have to be considered and addressed as part of the device validation. It should be noted that these safety concerns are largely similar to other regulated high risk medical devices and are not additional regulatory requirements. •Like all other medical devices, medical devices for modification of appearance or anatomy (Annex A) undergo changes as part of their product life cycle. Please refer to GN-21: Guidance on Change Notification for Registered Medical Devices to determine whether a Change Notification submission to HSA is required for specific proposed changes to a medical device that is registered on the Singapore Medical Device Register (SMDR). Product Registration Annex A: Positive list of high risk products intended for modification of appearance or anatomy Specific risksto be addressed Any implant for the modification or fixation of any body part Examples: breast implant gluteal implant -Toxicity andlong-term safety of the implant Documentary requirements including but not limited to: Biocompatibility studies Mechanicaltesting (e.g. elongation, rupture resistance test, fatigue test) Raw material certificate of analysis (COA) Device labeling requirement (breast implants) A statement indicating that breast implants are indicated for breast augmentation for patients of at least 18 years of age for saline-filled implants and of at least 22 years of age for silicone-filled implants or similar wording has to be presented in the product labelling. Table 2: Safety Concerns Product Registration Annex A: Positive list of high risk products intended for modification of appearance or anatomy Specific risksto be addressed Any injectable dermal filler or mucous membrane filler Examples: soft tissue fillers wrinkle fillers -Safety and toxicity of the implantand itsdegradation products Documentary requirements including but not limited to: Biocompatibility studies Degradationprofile studies Safety of biological material (e.g. animal/microbial-derived material) Raw material COA Device labeling requirement: Thetreatment dose limit per year* has to be stated in the product labelling *Justification for the treatment dose limit per year should take into account the volumes administered in clinical studies and/or results obtained from preclinical studies. Table 2: Safety Concerns (continued) Product Registration Annex A: Positive list of high risk products intended for modification of appearance or anatomy Specific risksto be addressed Any instrument, apparatus, implement, machine or appliance intended to be used for the removal or degradation of fat by invasive means Examples: liposuction equipment Invasive lipolysisequipment -Safetyof the device Documentary requirements including but not limited to: Electrical safety Functional testing Table 2: Safety Concerns (continued) Dealers License Requirements • To engage in the manufacture, import and/or wholesale of medical devices for modification of appearance or anatomy (Annex A) in Singapore, the appropriate dealer licenceswill need to be obtained from HSA. • The submission requirements and process will follow as per GN-02: Guidance on Licensing for Manufacturers, Importers and Wholesalers of Medical Devices. • This licensing requirement is to ensure proper traceability and post- market monitoring of devices for modification of appearance or anatomy (Annex A) marketed in Singapore. Post-market Obligations • Dealers of medical devices are obliged to perform post-market duties, including but not limited to reporting of adverse events, defects and recall to HSA and ensuring appropriate investigation, so as to ensure the continued safe use of the devices. • Healthcare professionals and users of medical devices for modification of appearance or anatomy (Annex A)may also report any adverse events related to the use of a medical device or device failure related issues to HSA on a voluntary basis.

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4. Conclusion

• This is the current position based on a risk-based regulatory approach and the current knowledge of foreseeable risks associated with devices for modification of appearance or anatomy (Annex A). • Where deemed necessary, HSA may expand the positive list of high risk devices intended for modification of appearance or anatomy (Annex A) based on new scientific information to protect public health and safety