STOP U Model UXV Device

K203665 · Pollogen, Ltd. · PAY · Feb 25, 2021 · General, Plastic Surgery

Device Facts

• Record ID: K203665
• Device Name: STOP U Model UXV Device
• Applicant: Pollogen, Ltd.
• Product Code: PAY · General, Plastic Surgery
• Decision Date: Feb 25, 2021
• Decision: SESE
• Submission Type: Special
• Regulation: 21 CFR 878.4420
• Device Class: Class 2
• Attributes: Therapeutic

Intended Use

The STOP U Model UXV device is intended for use in the non-invasive treatment of mild to moderate facial wrinkles for adult users who have Fitzpatrick Skin Types II-IV.

Device Story

STOP U Model UXV is a home-use electrosurgical device for aesthetic wrinkle reduction. It delivers bipolar RF energy (1 MHz) to dermis and subcutaneous layers to generate heat via electrical impedance. Device consists of applicator unit, power supply, and preparation gel. User operates device on facial skin; integrated temperature sensor monitors skin temperature and automatically disables or reduces RF transmission upon reaching maximum threshold to prevent overheating. Output is thermal energy; intended to improve appearance of facial wrinkles. Device is intended for lay person use in home environment.

Clinical Evidence

Bench testing only. Verification testing confirmed technical specifications for max RF power output, vibration, and buzzer functionality. Electrical safety, EMC, and software validation were performed per FDA guidance and relevant IEC/ISO standards. No clinical data provided.

Technological Characteristics

RF bipolar energy; 1 MHz frequency; 5.7W max RMS power; 4 electrodes with 6mm spherical diameter. Includes temperature sensor for thermal regulation. Biocompatible per ISO 10993-1. Complies with IEC 60601-1, 60601-1-2, 60601-1-6, 60601-1-11, 60601-2-2, and ISO 14971. Power source 100-240V.

Indications for Use

Indicated for non-invasive treatment of mild to moderate facial wrinkles in adults with Fitzpatrick Skin Types II-IV.

Regulatory Classification

Identification

An electrosurgical device for over-the-counter aesthetic use is a device using radiofrequency energy to produce localized heating within tissues for non-invasive aesthetic use.

Special Controls

*Classification.* Class II (special controls). The special controls for this device are:(1) Non-clinical performance data must demonstrate that the device meets all design specifications and performance requirements. The following performance characteristics must be tested: Over-heating, power accuracy radiofrequency, pulse cycle, waveform, pulse duration, and device characterization parameters. (2) Label comprehension and self-selection performance evaluation must demonstrate that the intended over-the-counter users can understand the package labeling and correctly choose the device for the indicated aesthetic use. (3) Usability performance evaluation must demonstrate that the over-the-counter user can correctly use the device, based solely on reading the directions for use, to treat the indicated aesthetic use. (4) Clinical performance evaluation must demonstrate that the device performs as intended under anticipated conditions of use to achieve the intended aesthetic results. (5) The patient-contacting components of the device must be demonstrated to be biocompatible. (6) Instructions for cleaning the device must be validated. (7) Performance data must be provided to demonstrate the electromagnetic compatibility and electrical safety, including the mechanical integrity, of the device. (8) Software verification, validation, and hazard analysis must be performed. (9) Labeling must include: (i) Warnings, precautions, and contraindications to ensure the safe use of the device for the over-the-counter users. (ii) A statement that the safety and effectiveness of the device's use for uses other than the indicated aesthetic use are not known. (iii) A summary of the clinical information used to establish effectiveness for each indicated aesthetic usage and observed adverse events.

Predicate Devices

• Pollogen Ltd., STOP U (K182774)

Submission Summary (Full Text)

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Image /page/0/Picture/0 description: The image contains the logo of the U.S. Food and Drug Administration (FDA). On the left is the Department of Health & Human Services logo. To the right of that is the FDA logo, which is a blue square with the letters "FDA" in white. Underneath the square are the words "U.S. FOOD & DRUG ADMINISTRATION" in blue.

February 25, 2021

Pollogen Ltd. % Elissa Burg Regulatory Consultant BioVision Ltd. Had Nes 183 Had Nes, 1295000 Israel

Re: K203665

Trade/Device Name: STOP U Model UXV Device Regulation Number: 21 CFR 878.4420 Regulation Name: Electrosurgical Device for Over-The-Counter Aesthetic Use Regulatory Class: Class II Product Code: PAY Dated: January 26, 2021 Received: January 28, 2021

Dear Elissa Burg:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database located at https://www.accessdata.fda.gov/scripts/cdrl/cfdocs/cfpmn/pmn.cfm identifies combination product submissions. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

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Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting of medical device-related adverse events) (21 CFR 803) for devices or postmarketing safety reporting (21 CFR 4, Subpart B) for combination products (see https://www.fda.gov/combination-products/guidance-regulatory-information/postmarketing-safety-reportingcombination-products); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR 4. Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to https://www.fda.gov/medical-device-safety/medical-device-reportingmdr-how-report-medical-device-problems.

For comprehensive regulatory information about medical devices and radiation-emitting products, including information about labeling regulations, please see Device (https://www.fda.gov/medicaldevices/device-advice-comprehensive-regulatory-assistance)and CDRH Learn (https://www.fda.gov/training-and-continuing-education/cdrh-learn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See the DICE website (https://www.fda.gov/medical-device-advice-comprehensive-regulatoryassistance/contact-us-division-industry-and-consumer-education-dice) for more information or contact DICE by email ([e-mail]) or phone [phone] or 301-796-7100).

Sincerely.

Long Chen, Ph.D. Assistant Director DHT4A: Division of General Surgery Devices OHT4: Office of Surgical and Infection Control Devices Office of Product Evaluation and Ouality Center for Devices and Radiological Health

Enclosure

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# Indications for Use

510(k) Number (if known) K203665

Device Name STOP U Model UXV

Indications for Use (Describe)

The STOP U Model UXV device is intended for use in the non-invasive treatment of mild to moderate facial wrinkles for adult users who have Fitzpatrick Skin Types II-IV.

Type of Use (Select one or both, as applicable)

| Prescription Use (Part 21 CFR 801 Subpart D)

X Over-The-Counter Use (21 CFR 801 Subpart C)

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### VI. 510(k) SUMMARY

#### Pollogen Ltd.'s STOP U Model UXV Device - K203665

- Pollogen Ltd. Applicant's name: 6 Kaufman St. Tel Aviv ISRAEL 6801298 Tel. [phone] Fax [phone]
- Elissa Burg Contact Person: Regulatory Consultant BioVision Ltd. Had Nes 183 Israel 1295000 Tel. [phone] Fax [phone]

Date Prepared: February 24, 2021

Name of Device: STOP U Model UXV

Common or Usual Name: Electrosurgical device for over-the-counter aesthetic use

Classification: Product Code: PAY Regulation No: 21 C.F.R. §878.4420 Class: II Classification Panel: General & Plastic Surgery

Predicate Device: Pollogen Ltd., STOP U (K182774)

### Intended Use / Indications for Use

The STOP U Model UXV device is intended for use in the non-invasive treatment of mild to moderate facial wrinkles for adult users who have Fitzpatrick Skin Types II-IV.

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### Modified Device Description

The STOP U Model UXV device delivers RF current into the skin to generate heat through electrical impedance in the dermis and subcutaneous layers. The device consists of the following components and accessories: The STOP U Model UXV device (applicator unit), the STOP U Model UXV Power Supply and the STOP Preparation Gel.

#### Comparison of Technological Characteristics

The TriPollar™ STOP U Model UXV device delivers RF energy at a frequency of 1 MHz (+/-10%) and a maximum output RMS power of 5.7 watts (+/- 10%) into the skin through its electrodes. The device generates heat through electrical impedance in the dermis and subcutaneous layers. The temperature sensor located in the electrodes area constantly monitors the skin temperature and disables/reduces RF transmission once the maximal skin temperature is obtained.

The following table compares the modified STOP U Model UXV device to the predicate device with respect to intended use, technological characteristics and principles of operation, providing detailed information regarding the basis for the determination of substantial equivalence.

| | Proposed Device:<br>STOP U Model UXV<br>(K203665) | Predicate Device:<br>STOP U (K182774) |
|-----------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Manufacturer | Pollogen® Ltd. | Pollogen® Ltd. |
| Device Class | Class II | Class II |
| Regulation Description | Electrosurgical device for over-<br>the-counter aesthetic use | Electrosurgical device for over-the-<br>counter aesthetic use |
| Regulation Number | 21 C.F.R. 878.4420 | 21 C.F.R. 878.4420 |
| Product Code | PAY | PAY |
| Intended Use /<br>Indications for Use | The STOP U Model UXV device<br>is intended for use in the non-<br>invasive treatment of mild to<br>moderate facial wrinkles for adult<br>users who have Fitzpatrick Skin<br>Types II-IV | The STOP U device is intended for<br>use in the non-invasive treatment of<br>mild to moderate facial wrinkles for<br>adult users who have Fitzpatrick<br>Skin Types II-IV |
| Deep tissue<br>Heating<br>Electromagnetic<br>Energy | RF | RF |
| Modes of Operation | RF Bipolar Energy | RF Bipolar Energy |
| Nominal Operating RF<br>Power (200 Ohms) | 5.7W (+/- 10%) | 5.7W (+/- 10%) |
| | Proposed Device:<br>STOP U Model UXV<br>(K203665) | Predicate Device: STOP U<br>(K182774) |
| RF Carrier Frequency | 1MHz (+/- 10%) | 1MHz (+/- 10%) |
| Waveform | Sinusoid | Sinusoid |
| Applicator Effective<br>Area | 1 cm² | 1 cm² |
| Total Power Density<br>(fluence) | 5.7 W/cm² (+/- 10%) | 5.7 W/cm² (+/- 10%) |
| Output Voltage of Power<br>Source | 8V DC | 8V DC |
| Output Current of<br>Power Source | 1.5A | 2.5A |
| Dimensions | H=134mm; L=51mm; W=32mm | H=134mm; L=51mm; W=32mm |
| Weight | 85 gr | 85 gr |
| RF Energy Emission<br>Indicator | Yes (Temp. sensor) | Yes (Temp. sensor) |
| Energy Source | 100-240V, 50-60Hz, 0.4A | 100-240V, 50-60Hz, 0.6A |
| Heating Levels | 1 | 1 |
| Electrodes | 4 | 4 |
| Diameter of Spherical<br>Portion of Electrodes | 6mm | 4mm |
| Biocompatibility | All parts that are in<br>contact with patient comply with<br>the requirements of ISO<br>10993-1 | All parts that are in<br>contact with patient comply with<br>the requirements of ISO<br>10993-1 |
| Software | Verified and validated<br>according to the FDA<br>guidance | Verified and validated<br>according to the FDA<br>guidance |
| Intended Operating<br>Environment | Home Use Device | Home Use Device |
| Intended Operator | Lay Person | Lay Person |
| Testing | Electrical safety & EMC | Electrical safety, EMC, & Usability<br>Study |

Special 510(k) Submission - STOP U Model UXV Device - Pollogen Ltd.

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# Performance Data

Pollogen conducted several performance tests to demonstrate that the STOP U Model UXV device complies with performance standards and that it functions as intended.

- Verification test demonstrating that the STOP U Model UXV meets the system's technical specification for the, max RF power output, vibration parameters and buzzer functionality.
- -Electrical safety and compatibility testing was performed to validate that the STOP U Model UXV's power control and accuracy is in reference to the user's input.
- The STOP U Model UXV software was validated as required. -

In all instances, the STOP U Model UXV device functioned as intended and observations were as expected.

# Performance Standards

The STOP U Model UXV device complies with the following performance standards:

- IEC/EN 60601-1 Edition 3.1 Medical Electrical Equipment Part 1: General requirements . for safety (2005) and A1:2012.
- IEC 60601-1-6 Medical Electrical Equipment Part 1-6: General requirements for basic ● safety and essential performance - Collateral standard: Usability (2010/AMD2013).
- IEC 60601-1-11:2015 (2nd edition), Medical electrical equipment Part 1-11 General . requirements for basic safety and essential performance - Collateral Standard: Requirements for medical electrical equipment and medical electrical systems used in the home healthcare environment.
- IEC/EN 60601-2-2 Medical Electrical Equipment Part 2-2: Particular requirements for . the basic safety and essential performance of high frequency surgical equipment and high frequency surgical accessories (Edition 6.0 2017-03).
- IEC 62304 Medical device software - Software life cycle processes (2006, Ed. 1/AMD A1:2015).
- IEC 60601-1-2 Medical Electrical Equipment Part 1-2: General requirements for basic . safety and essential performance - Collateral Standard: Electromagnetic disturbances -Requirements and tests (2014, Ed. 4).
- ISO 15223-1:2016- Medical devices -- Symbols to be used with medical device labels, . labeling and information to be supplied - Part 1: General requirement.
- ISO 14971:2007 Medical devices Application of risk management to medical devices. ●

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# Conclusion

The STOP U Model UXV device is as safe and effective as its predicate, Pollogen's STOP U device (K182774) for the requested intended use. The STOP U Model UXV device has the same intended use and indications for use and similar technological characteristics and principles of operation as its predicate. Performance data demonstrated that the minor technological differences in the STOP U Model UXV device do not raise any issues of safety or effectiveness in comparison to the predicate device. Thus, the STOP U Model UXV device is substantially equivalent to its predicate, Pollogen's STOP U device (K182774) for the requested intended use.