Establishment Labs - Q3 2023

Transcript

Operator (participant)

Good afternoon. Welcome to Establishment Labs' Q3 2023 earnings call. At this time, all participants will be in a listen-only mode. At the end of this call, we will open the line for questions and answer session, and instructions will follow at that time. As a reminder, today's call is being recorded. I will now turn the call over to Raj Denhoy, Chief Financial Officer. Please go ahead.

Raj Denhoy (CFO)

Thank you, Operator, and thank you, everyone, for joining us. With me today is Juan José Chacón-Quirós, our Chief Executive Officer. Following our prepared remarks, we'll take your questions. Before we begin, I would like to remind you that comments made by management during this call will include forward-looking statements within the meaning of federal securities laws. These include statements on Establishment Labs' financial outlook and the Company's plans and timing for product development and sales. These forward-looking statements are based on management's current expectations and involve risks and uncertainties. For discussion of the principal risk factors and uncertainties that may affect our performance or cause actual results to differ materially from these statements, I encourage you to review our most recent annual and quarterly reports on Form 10-K and Form 10-Q, as well as other SEC filings, which are available on our website at establishmentlabs.com.

Please also note that Establishment Labs received an investigational device exemption from the FDA for Motiva Implants and is undergoing a clinical trial to support regulatory approval in the United States. We continually seek to expand the geographies in which our products are regulatory approved. Please check with your local authority for specific product availability. The content of this conference call contains time-sensitive information, accurate only as of the date of this live broadcast, November 7, 2023. Except as required by law, Establishment Labs undertakes no obligation to revise or otherwise update any statement to reflect events or circumstances after the date of this call. With that, it is my pleasure to turn the call over to our CEO, Juan José.

Juan José Chacón-Quirós (CEO)

Thank you, Raj, and good afternoon, everyone. Revenue in the Q3 of 2023 totaled $38.5 million, in line with the Q3 of 2022. Our results this quarter reflected lower demand for breast procedures globally. This lower demand developed over the quarter in our direct markets and was also reflected in orders we received from our distributors, and we expect this trend will persist in the Q4. As such, we are lowering our full year guidance to approximately $165 million, representing annual growth of 2% over 2022. I would note that while we still expect China approval by the end of this year, we have removed it from our guidance as we have less than two months remaining in this year. This is a meaningful portion of our reduction in guidance.

However, even in this period, we continue to gain accounts around the world. This slowdown seems fairly broad across aesthetics and does not seem to be related to anything specific in the breast implant industry. While anecdotal, in international markets, both plastic surgeons and dermatologists report to us they have seen a noticeable slowdown in their practices across all procedure types, both surgical and non-surgical. This is, of course, not a first for the aesthetics industry, and both precedent and our experience suggests that this will be transitory and relatively short-lived. That said, we are being very careful in this environment, and we have taken steps to make sure our business is spending in relation to the current demand. Among the steps we are taking are a reduction in global headcount and a reduction in operating expenses.

We are also prioritizing our main growth initiatives, the United States, China, and EMEA, as well as cautiously managing our global inventory levels. Even as we take these steps, we expect growth to resume in 2024, which includes doubling our TAM through our entry into United States and China. Our access to capital is a significant advantage here, and we are positioning ourselves to take advantage as demand inevitably returns to our industry. There has been worldwide dislocation in the competitive markets for breast implants, and this presents a sizable opportunity. It is also important to note that we continue to grow our market share. Our internal data shows that we continue to gain surgeon accounts in our markets and our competitive positioning is strengthening. We are taking market share globally, and this should continue through the remainder of 2023 and into 2024.

We are raising the standard of what women and surgeons should expect from the technologies they choose, and we are distancing ourselves from the remaining players in this industry. Our pipeline of new products and new geographic markets will help fuel our momentum, and we have a very solid foundation on which to build for 2024 and beyond. Raj will provide additional details on our Q3 performance and our outlook in a moment, but I would like to highlight that we expect to be EBITDA positive by the end of 2024 and cash flow positive in 2025. These are corporate goals that are reflected throughout our business planning and are of the utmost priority. On October 15th, we announced that the US FDA granted 510(k) clearance for the Motiva Flora SmoothSilk Tissue Expander.

This was a major milestone for the company as it is our first implantable approved for the United States. Flora offers several proprietary and unique innovations, including Establishment Labs' patented SmoothSilk surface technology. SmoothSilk was the subject of the landmark paper published in Nature Biomedical Engineering by MIT scientist Bob Langer, in which the surface was shown to be the most biocompatible compared to other implantable surfaces. Flora also includes an RFID-enabled, non-magnetic port and is labeled as MR conditional by the FDA. By being magnet-free, Flora avoids the interference that magnets cause during MR imaging and can improve the precision of radiation oncology treatment.... This is a distinct advantage to Flora, as all other commercially available breast tissue expanders include magnets.

In the FDA's letter on Flora approval, the agency noted, "This is an innovative technology not available in other tissue expanders on the market." Flora has been available outside the US since 2021. We are gaining traction with the device. There have been several notable independent publications highlighting improved patient comfort with Flora compared to other devices, and improved imaging and radiation treatment outcomes. Despite one in eight women developing breast cancer, tissue expanders have seen little innovation in decades. With Flora, we are providing surgeons and the women who receive these devices a better option, and we are extremely proud of being able to offer Flora to women in the United States. We began to introduce Flora to plastic surgeons in the United States at the annual meeting of the American Society of Plastic Surgeons in Austin at the end of October, and the reception was highly encouraging.

Leading plastic surgeons at some of the top institutions in America have indicated that they will begin to adopt Flora as their expander of choice. In October, we held our eighth World Symposium on Ergonomic Implants in Lisbon, Portugal. Among the highlights was a presentation of two-year results from the Mia feasibility clinical study. The Mia study is an IRB-approved, prospective study that enrolled the first 100 subjects between December 2020 and April 2021. In the preliminary two-year Kaplan-Meier analysis of key events, there were no reports of capsular contracture and no ruptures. A sub-study of 33 subjects who underwent an MRI at 18 months also showed no ruptures. There were no reports of bleeding, hematoma, or seroma requiring intervention in the study.

These are among the best results shown at 2 years for any breast implant technology and add further support that Mia FemTech is an entirely new category within breast aesthetics. With Mia, a plastic surgeon can shape the breast in a 15-minute, minimally invasive procedure without the need for general anesthesia. The result is natural and discreet, with a 1-2 cup proportionate result. The procedure requires minimal downtime, with women returning to most activities the same day. By providing a solution that overcomes many of the obstacles of traditional breast augmentation, we are opening up a whole new group of women to breast aesthetics. Our list of countries where Mia is available continues to grow.

We have partner sites in Spain, Switzerland, Sweden, Germany, France, Costa Rica, and Japan, and we have partnered with our distributors in Turkey and the Middle East to begin opening sites in those regions in 2024. It is early in the launch of Mia, but we are seeing proof points that we are creating and capturing demand for this new category. One recent Mia consumer is Yokasta Valle. Yoka is a professional female boxer, and just this past weekend, she defended her International Boxing Federation and World Boxing Organization mini lightweight titles by unanimous decision. Yoka has now defended her world titles twice, just months since her Mia procedure. She's not only an inspiration as a world-class athlete, but is also a testament to how women can quickly return to their lives with Mia without limitation or restrictions.

Already, we have reports of women flying internationally from the United States to receive the procedure abroad. In some cases, they are paying in excess of $20,000 for a premium experience. This is more than twice the cost of the average breast augmentation in the United States. Stories like these demonstrate that not only is this a new category in breast aesthetics, but that Mia is going to be firmly in the luxury category and highly aspirational. The momentum for Mia continues to build, and both awareness and lead generation continue to grow. This will eventually be converted into more procedures taking place at our Mia-certified partner clinics. The launch of a new platform like Ergonomix2, which include the implants for JOY and Mia, is an opportunity to price technology according to consumers' willingness to pay.

Thus, we are glad to see the contribution to our total revenue of the Joy program now exceed 10% of our total implant revenue, with an average selling price of more than double our blended round and Ergonomix pricing. We are beginning to see positive contribution to our gross margins from this platform. As JOY and Mia scale, ASP and gross margins will improve in the international markets. The United States and China have the highest prices in the world and would be significantly accretive to ASP and gross margins. All of this together lays the foundation for a very strong company. We are actively preparing for the launch of Motiva in China with our distribution partner as we wait for the letter of approval from the NMPA for Motiva implants.

In the US, the final module of our PMA was submitted to the FDA in the Q1 of 2023, and the full PMA remains under review by the agency. The pace of activity and our interactions with the agency remains very positive. It is notable that while the recent approval of Flora and the approval of Motiva are separate processes, the devices share the same surface technology, similar RFID technology, and are manufactured under the same conditions at the same facility. We recently hired Liz Newman to lead our US business. Liz brings over 30 years of experience launching and growing aesthetic brands. She's moving quickly to build out the commercial and operational teams and is finalizing plans for launch. We look forward to sharing more with you about our progress over the coming months.

Our confidence that Motiva Implants will soon be available to women in the United States continues to grow. I will now turn the call over to Raj.

Raj Denhoy (CFO)

Thank you, Juan José. Total revenue for the Q3 was $38.5 million, which was growth of 0.8%. From a regional perspective, sales in Europe, Middle East, and Africa were approximately 61% of the global total. Asia Pacific was 6% and Latin America, 33%. Direct sales were approximately 54% of implant sales, while distributors made up the balance. Brazil, which is our single largest market globally, accounted for approximately 16% of total quarterly sales. Our gross profit for the Q3 was $26.1 million, or 67.7% of revenue, compared to $26 million, or 68.1% of revenue for the same period in 2022. Our gross profit in the Q3 was positively impacted by increased contribution of Mia revenue. This was partially offset by higher overhead and labor costs.

Costs were higher, in part, from changes in exchange rates between the US dollar and the Costa Rican colón. As we report in US dollars, the revaluation of the colón over the last year resulted in higher costs in the period. Average selling prices in the Q3 are up from the Q2 of 2023 and year-over-year. SG&A expenses for the Q3 increased approximately $8.7 million to $40 million, compared to $31.3 million in the Q3 of 2022. The increase in SG&A in the Q3 resulted in part from our investments in new growth initiatives like MIA and preparations for a launch in the US R&D expenses for the Q3 increased approximately $1.8 million from the same quarter a year ago to $7.1 million.

Higher personnel costs and increased activities related to our US approval processes contributed to the higher spending this period. Total operating expenses for the Q3 were $47.1 million, an increase of approximately $10.5 million from the year-ago period. Net loss from operations in the Q3 was $29.3 million, compared to a net loss of $18.6 million in the same period of 2022. Our cash position as of September thirtieth was $52.2 million, compared to $66.4 million at the end of 2022.

Our cash use in the Q3 included approximately $6.6 million of investment in CapEx, including for our new manufacturing facility, which is now complete, as well as a $13.9 million increase in inventory as we prepare for the launches of Motiva in China and the United States. As a reminder, we have two remaining tranches on our debt facility, which total $50 million and which become available on the achievement of sales and regulatory milestones. These, along with the cash on hand at the end of the Q3, provide us with access to approximately $100 million in capital. As Juan Jose noted, we are lowering full-year revenue guidance to approximately $165 million. The updated guidance reflects lower demand globally, but also that we removed China from our forecasts.

We expect approval in China this quarter, but at this late point in the year, we are not forecasting any revenue contribution in 2023. The reduction in guidance is approximately two-thirds from the changes in demand and one-third from China timing. We continue to expect gross margin in 2023 to be approximately 100 basis points lower than 2022. We are taking steps to control expenses and cash use. This includes a target of 20% reduction in global personnel costs, focused reductions in operating expenses, and management of inventory levels. As a result, we expect cash use in the Q4 to be meaningfully lower than in the Q3. Our objective is to reduce cash use to less than $15 million in the Q4, and based upon the actions we have taken thus far, we are confident we will meet this target.

With these actions, we expect to be EBITDA positive in 2024 and cash flow positive in 2025. We believe we can achieve these targets with the cash we have on hand and with the additional credit available to us. These are very important core objectives for Establishment Labs and will be reflected in our corporate planning as well as in our compensation structure for employees. I will now turn the call back to Juan José.

Juan José Chacón-Quirós (CEO)

Thank you, Raj. Establishment Labs is taking share, and we expect to continue to do so. The clinical and scientific data supporting the use of our products is unprecedented and only grows stronger, and you are seeing this affect many of our competitors. With our entries into the US and China, we will double our addressable markets, and we are poised to become the leading global company in breast aesthetics and reconstruction. Over the next few years, we will continue to transform and expand our markets by creating new categories with innovations like Mia Femtech. We are very excited about our future and expect strong growth for many years to come. Our 2026 target of $500 million in revenue remains a key long-term corporate objective, and everything I see suggests we will be successful. I will now turn the call over to the operator for your questions.

Operator (participant)

If you would like to ask a question, please press Star, followed by the number one on your telephone keypad. If you would like to withdraw your question, please press Star one. We ask that you limit yourselves to one question and one follow-up. Your first question comes from the line of Matt Taylor from Jefferies. Please go ahead.

Mike Sarcone (Equity Analyst, Medical Supplies and Devices)

Great. Thank you. This is Mike Sarcone on for Matt. Thanks for taking the question. Just to start, you mentioned you expect growth to resume in 2024. I was hoping you could comment on that and just, you know, talk about your visibility and your confidence there. And if you could, maybe parse out growth expectations for existing markets versus, you know, the growth that you'd be expecting for newer markets that you're entering into, like China and the US

Juan José Chacón-Quirós (CEO)

Yes, of course. First, I'll say that we are seeing the slowdown across aesthetics and in many markets globally, and surgery is often the tip of the spear, as the procedures are more costly and require more of a commitment. However, our experience and precedent does show that these trends are usually transitory and that demand for the procedures will tend to grow over time... Now, if you think about, like, you know, this softness in all those, all of aesthetics, you know, and you think about the position of Establishment Labs, in front of us, we have, you know, many growth opportunities that are real. The approval in China, the approval in the US, both of those are ASP and gross margin accretive, and we are, thanks to both of them, doubling our total addressable market. We received already the approval for Flora in the United States.

That's a $180 million market, and Flora is unique in its technology and can truly transform this market in the United States. And on top of that, we have Mia, which continues to expand and, you know, we will see Mia in more geographies next year. So, you know, beyond what we are seeing in terms of the softness, there is, you know, all the greenfield that we see ahead of us in terms of these new opportunities. There may be a time where like, you know, the the softness starts to clear out, and then we see growth in the traditional market. But I think, between all of it, we're poised to come back to a percentage of growth like we had seen in the past of 30%+.

Mike Sarcone (Equity Analyst, Medical Supplies and Devices)

Got it. That's helpful. Thank you. And Raj, I think you mentioned, you know, a 20% reduction in global personnel costs, you know, reducing certain OpEx. Can you talk about how quickly you plan to implement that? And then, you know, what would the ramp back look like when you do get approval in China and the US and you might need to increase headcount again?

Raj Denhoy (CFO)

Sure. So we've actually already undertaken a lot of these initiatives in the last couple of weeks. So we did have a reduction in force last week. So a lot of this is already happening. I think as Juan José noted in his remarks, you know, what we are doing at this point is prioritizing the growth objectives in front of us. So things like Mia, the United States, China. So we are making sure that we are committing our resources into those areas which provide the best opportunities for growth. And so you mentioned the US, for instance. In our prepared remarks, we also talked about how we have hired ahead of the US business at this point, and we're building out the teams there.

So we really think about it as sort of a reduction in certain areas of the business, you know, that are a little slower right now and emphasizing areas where we still have a lot of growth ahead of us. As these markets recover, which we expect they will, our core markets, we will continue to add back there. You know, we expect, as Juan José mentioned, to get back on a nice growth trajectory in these markets. We're just trying to be judicious in this period where things are slower.

Mike Sarcone (Equity Analyst, Medical Supplies and Devices)

Got it. Thank you very much.

Operator (participant)

Your next question comes from the line of Allen Gong from JP Morgan. Please go ahead.

Allen Gong (VP, Equity Research)

Hi. Sorry, it's a bit loud where I am. I tried to slip both questions in the same time. But, you know, just one question on your EBITDA and flow targets, right? With kind of the market a little bit softer than expected and, you know, China coming a little bit later and US potentially being a challenged market as well next year, what are you really assuming for, you know, these new markets to get to those targets? And then just as a quick follow-up, when I think about Mia, good to see it here, having success internationally, but as we think about the pipeline to the US. Thank you.

Raj Denhoy (CFO)

So, yeah, Allen, I can take the first question. I mean, when we look at the, you know, the outlook for 2024, we're preparing for a number of potential outcomes there, right? Where the markets don't recover for a period of time, and we're relying upon the growth of the new initiatives, which Juan José mentioned. You know, in most scenarios, with Mia ramping, you know, with China coming online, with Flora now approved, you know, we expect that growth will pick up next year, even based just upon those three things that we already know about, even if the core markets remain soft for a period of time. However, you know, we are preparing our budgets and spending for the eventuality that things don't improve for a period of time.

So we expect to be EBITDA positive, you know, even in a market where, you know, where these core markets remain soft for a period of time. And then I think your second question, which was on Mia, so I think Juan José.

Juan José Chacón-Quirós (CEO)

Yeah. Could you clarify the second question? It's very hard to hear you.

Raj Denhoy (CFO)

I think we might have lost Allen. Operator?

Operator (participant)

Allen, your line is open.

Allen Gong (VP, Equity Research)

Oh, sorry. Yeah, my question is just, you know, it's great to hear Mia doing really well internationally, but just curious, you know, once you get the Motiva approval in the US, how quickly do you think you will be bringing Mia to the US as well?

Juan José Chacón-Quirós (CEO)

Yeah, it's too early to give you a lot of precision on that because we first need to gain the approval of Motiva Implants, and based on that approval, seek a supplement for, you know, the implant that is necessary for the Mia procedure, and then there's the additional tools. So as a result, what I can tell you is that our regulatory experts believe that this is a supplement. Supplements usually used to take around 18 months. So of course, you know, we're very committed to the first approval, which is the one of Motiva Implants, so that we can then bring, you know, the rest of the pipeline of innovation that is already available in the international market.

Operator (participant)

Your next question comes from the line of Anthony Petroni from Mizuho Group. Please go ahead.

Anthony Petrone (Managing Director Equity Research)

Thanks, and good afternoon. Maybe I'll start with the global demand comments and, you know, the Establishment Labs numbers are following some similar comments from Sientra, player that's no longer going to be in the marketplace. InMode previously as well talked about weakening demand. And I guess when we kind of pinpoint it, is it that the underlying demand, because the consumer, you know, has been impacted here, because generally the consumer's tapped out and they're not—there's no indications of interest in the funnel?... Or conversely, you know, you see the reports today, credit card debt hit over $1 trillion. And if you think of in the US here, folks like credit card, are the rates on lending just, have they gotten too high and that's impacted demand?

Is there still underlying demand for the procedures, but is it more funding issue, or has the demand simply gone away while there's a prioritization of spend here? I'll have a couple follow-up

Juan José Chacón-Quirós (CEO)

Yeah. Thank you, Anthony. What I'll tell you is that the slower demand developed over the quarter in our direct markets, and eventually was reflected as well in the orders that we received from our distributors. You know, in the first half of the year, around 60% of our orders came from distributors. So we normally do see a slowdown in procedures in late summer, and then they tend to recover once, you know, the seasonality disappears, and in September, we see it pick it, you know, pick up again. Well, that did not happen this year. What we hear from doctors is that many patients are basically delaying the procedures. It's not because of lack of interest.

I think, there is a lot of, you know, uncertainty, both, macroeconomic and geopolitical, and it is having an impact in all of aesthetics. However, in the past, we have seen this many times in which, you know, periods like this in the international markets for whether, you know, one type of crisis or another, they do come back. And in our case, I think what, what makes us even more confident is that, you know, for that growth, we don't depend on the, you know, on the current market. We have new markets opening up. We've recently had the approval of Flora here in the United States, with a $180 million market opening to us.

And, you know, we're gonna see in the next few months, you know, the approval in China, and then further after that, you know, the approval in the United States. So all of that is, you know, is potential growth for us. And, and that's what makes us confident, because, you know, not all companies have these type of milestones ahead of them.

Anthony Petrone (Managing Director Equity Research)

No, fair enough. And then just, folks, one on cash preservation and just how we should be thinking about a Motiva launch under a scenario where we get FDA clearance. So first on cash, Raj mentioned that the burn rate would be limited to $15 million in 4Q. Just want to clarify that the cash burn is limited to $15 million. So is that kind of the level we should be thinking about for the first half of 2024? And then when you think about putting funding toward a potential US Motiva launch here, should we get FDA clearance, is it more of a gradual launch now where you're not really gonna go full tilt, or is that unchanged, where it would be a full market clearance next year? Thanks.

Raj Denhoy (CFO)

Yeah, to your question, Anthony, I think that $15 million level in the Q4, again, you know, you've seen the guidance reduction that we've given, right? It's gonna be a very, you know, slow top-line growth quarter, and we're, you know, guiding to about $15 million of cash use. As we move into next year and some of these opportunities, China, you know, Flora in the United States, the continued growth of Mia, you know, we're looking at keeping our cash use at that level, if not lower, going forward. We did talk about getting to be EBITDA positive by the end of next year, and then ultimately getting to cash flow positive on the cash we currently have access to. The preservation of cash is gonna continue to be a big focus of ours.

But I would look at it more as sort of the, you know, the use of it in areas that provide us with the best growth. And so you talk about the United States, it's the biggest opportunity in front of us, and we will not underfund that opportunity, but we'll look to find, you know, areas in the other parts of the business that we can lever and devote the capital to, again, to the United States.

Anthony Petrone (Managing Director Equity Research)

Thanks. I'll get back in queue.

Operator (participant)

Your next question comes from the line of Josh Jennings from TD Cowen. Please go ahead.

Josh Jennings (Managing Director, Senior Analyst, Medical Technology)

Hi, good afternoon. Thanks for taking the questions. I was hoping to just ask about China approval timeline. It sounds like the team's still optimistic that the approval could be at hand by the end of this year. Any signals from China regulators or process updates that you can share that that's driving that optimism? Or is it just the process has moved forward, you've done your job on your side and the approval will come, it's just a matter of time?

Juan José Chacón-Quirós (CEO)

Yeah. Thank you, Josh. I think that, you know, we have enough signals in front of us, to understand that, you know, the work on the final labeling is, you know, is done. Usually by that time, you know that you're gonna get the letter from the NMPA. And I think this is going to happen before the end of the year. At least that is our expectation. However, we now expect to begin recognizing revenue from that market in 2024. And, you know, as such, we are preparing for it. You know, we have been on calls with our team there on a weekly basis, and we are preparing for a launch that should happen early next year, if everything goes according to plan.

Josh Jennings (Managing Director, Senior Analyst, Medical Technology)

Thanks for that. And then just to follow up on the wanted to ask a question about the process of the Flora 510(k) approval. You now have Smooth Silk cleared in the United States. Was the 510(k) process independent of the PMA review process by the FDA? And did the FDA have to visit the manufacturing facilities prior to that for the 510(k) approval? Thanks for taking all the questions.

Juan José Chacón-Quirós (CEO)

Yes, on that, Josh, it is not the same process. One is a 510(k) that leads to a clearance, and the other one is a PMA that leads to an approval. However, it is the same division that is looking at both. And as such, you know, as part of the conversations for the clearance of the Flora Tissue Expander, they had to include people that, you know, have to do with the approval, potential approval of the Motiva implants. So definitely we have cleared an important hurdle when it comes to one of the most important things in the approval process for the Motiva implants, which is surface biocompatibility. You know, the surface is an important driver of safety, and as such-...

By having the clearance of Flora, we have, you know, a lot of confidence that we will finish the process, you know, as we expect with the Motiva Implants. And no, they did not, you know, inspect our manufacturing facilities for the Flora Tissue Expander, but it is the same manufacturing facilities, you know, equivalent processes that are used for the manufacture of Motiva Implants.

Operator (participant)

Your next question comes from the line of Neil Chatterji from B. Riley. Please go ahead.

Neil Chatterji (Senior Analyst, Medical Technology & Digital Health)

Hey, guys, good afternoon. Thanks for taking our questions. Yeah, just on the demand slowdown, I mean, you know, as far as, you know, I guess, are you seeing any nuances, I guess, between just the general aesthetic slowdown versus specifically the breast augmentation market and any indications that could come back faster for implants?

Juan José Chacón-Quirós (CEO)

So, like we said, you know, you tend to see it first in, you know, surgical aesthetic procedures because they tend to be more expensive, and they usually require more of a commitment. So that's why I think we're seeing it first there. When you look at, you know, the size of the impact, I think it is very important to understand that in direct markets, we are seeing an impact that is, you know, not more than 10%, for instance, in Europe. But in distributor markets, we are seeing a lot bigger of an impact. But that is related to the fact that distributors are very careful with their cash management. So if they think that they can get through, you know, a softer market by ordering less, they will do so.

So, you know, the impact as a percentage in our total revenue is a lot stronger. And, you know, until we get to the US, you know, the majority of our sales are going to go through the distributor channel. You know, so far this year, it's been, you know, like in the first half, it was around 60%, and in that... Now you saw that turn around completely with, you know, close to 55% of our, you know, revenue coming from direct markets.

So it kind of, like, amplifies the impact, but I think, you know, as we get, you know, through the rest of this year and, you know, the situation starts to resolve with our distributors, what I think you're going to see is a resumption of ordering patterns, because they are going to consume those inventories, and they will need to come back.

Neil Chatterji (Senior Analyst, Medical Technology & Digital Health)

Great, thanks for that color. Maybe just switching gears just to Mia. Just curious, you know, on any, you know, more updates on just the progress for the clinic partners there and the DTC efforts. You know, how much is the two-year initial Mia feasibility study results kind of helping generate leads and updates?

Juan José Chacón-Quirós (CEO)

Yeah, I think that's a really good point because the two-year study, which has 0% capsular contracture, 0% rupture, you know, 0% bleeding, all these things that people, you know, care about when they think about, you know, an innovative procedure like Mia, well, they, you know, they tend to dissipate in terms of questions and concerns. But I think what we see is two things. The number of clinics that are interested in becoming partner clinics is increasing. Actually, we're having almost a difficulty in onboarding and training fast enough these clinics so that they can begin, you know, transferring the awareness into leads. The second part is what we are doing with the clinics that have been already onboarded and are speaking to consumers.

You know, what we began with our awareness campaign is now turning into many leads coming to these clinics, and I think that is something that is very much appreciated in the period of softness, is that these clinics are seeing leads, and many of these leads are women who had not thought about, you know, a traditional breast augmentation. So I think, you know, Mia is going to be a shining light in the middle of this period of softness.

Neil Chatterji (Senior Analyst, Medical Technology & Digital Health)

Great. That's it for me. I'll just hop back in queue.

Operator (participant)

Your next question comes from the line of Joanne Wuensch from Citibank. Please go ahead.

Joanne Wuensch (Managing Director, Head of U.S. Healthcare Research)

Thank you very much for taking the questions. The last time you experienced this was when, and how long did it take you to, for lack of a better term, dig out of it? And my second question has to do with the FDA process. Where are you with that? Have they come in to inspect the facility? Anything you can sort of give us granular, granularly, I guess that's the right word, to help better understand where, where that is? Thank you.

Juan José Chacón-Quirós (CEO)

Yes. Thank you, Joanne. I think, you know, from an industry perspective, probably 2008, 2009 was the deepest recession ever experienced, and procedures, at least for the US, where you have the best figures, fell for two years, but then recovered back pretty strongly. Within a year after that, they were back to pre-recession levels. In the international market, actually, we see it a lot more often. We see, you know, countries like Brazil, Venezuela, Argentina, Mexico, who have, you know, periods in which they go through recessions or, you know, political instability, and that period tends to last a couple of quarters, and then they tend to resume. We've seen similar situations in Asia, you know, where like, you know-...

Growth stopped for a bit in certain markets like, you know, Thailand or, you know, in Southeast Asia, but, you know, they do tend to recover. So that gives us the confidence to tell you that, you know, although this may be transitory, we are also taking the steps necessary so that if it was to last longer, we are prepared for it. So that is perhaps one of the most important things that we are trying to convey today, is that, you know, based on the past, we know it, they will come back. We cannot predict the future, so we are getting prepared for it. And when it comes to the approval process for the PMA of Motiva Implants, you know, remember we went from a modular PMA to, you know, full PMA.

We have provided all the answers to all the questions, you know, for every module that the FDA gave us, and we are now awaiting for the manufacturing inspection. So as soon as we have that inspection, I think it will be a major milestone towards the approval. But once again, I do think that it was quite important to receive the clearance of the Flora tissue expander, because it is a good equivalent in terms of many of the characteristics that are part of the breast implant as well.

Joanne Wuensch (Managing Director, Head of U.S. Healthcare Research)

Thank you.

Operator (participant)

Your next question comes from the line of Marie Thibault from BTIG. Please go ahead.

Sam Eiber (Medical Technology Analyst)

Hey, good afternoon. This is Sam on for Marie. Thanks for taking the questions. Maybe I can start on the Flora approval that you guys just got here last month. I'm wondering if you guys can use that to essentially introduce the Motiva technology to customers that maybe are newer to Establishment Labs, considering it has similar properties like the Smooth Silk surface technology as the regular Motiva implant.

Juan José Chacón-Quirós (CEO)

Yeah, I think that's very important to us because if you think, you know, for the last few years, basically, whatever interaction US plastic surgeons had with Motiva came, you know, through international conferences that may have attended, friends of them in plastic surgery that have used the device and had told them about it. But basically, you know, many of the things that they heard was through the eyes of our competitors. So it is very important to us that now we have the possibility to introduce Establishment Labs, to talk about, you know, our commitment to science and technology. We can talk about, you know, the surface technology, which is one of the most important things when it comes to biocompatibility, and definitely about our RFID technology, because it is equivalent to what we have also available in the in the final implant.

You know, all of this is going to give us many opportunities to begin talking about, you know, what this company is about, which is women's health and the introduction of this concept into the US market for breast aesthetics and reconstruction eventually.

Sam Eiber (Medical Technology Analyst)

Okay, very good. And maybe I can use my follow-up here for Raj. You know, I know it's difficult right now to, you know, figure out how long this transitory environment could be, but, you know, assuming the implied Q4 guidance, $31.5 million, you know, would that be an appropriate run rate to, I guess, use for the core markets going forward in 2024? And, you know, then layering on top of that, some of the new markets as you guys open them up.

Raj Denhoy (CFO)

It's not a bad starting point. I mean, as Juan José noted, you know, we've seen a much bigger slowdown in our distributor markets than we've seen in our direct markets. And so, you know, we don't expect that that's gonna continue with that period of time, but as a conservative base to start from, that's not bad. But then you start to layer on top of it, you know, things like Mia, you know, Flora in the United States, you know, as Juan José mentioned, we're very close to Chinese approval. You know, that should contribute next year. So we have a lot of good things that build on top of that, and we do expect that, you know, the Q4 should really be the low water mark in terms of the demand we see for these products.

Sam Eiber (Medical Technology Analyst)

Got it. Thanks for taking the questions.

Operator (participant)

Your next question comes from the line of George Sellers from Stephens. Please go ahead.

George Sellers (VP, Equity Research Analyst, Medical Devices)

Hey, good afternoon, and thanks for taking the question. Maybe to start with Flora, I apologize if I've missed this, but I'm just curious what that commercialization might look like, what you're anticipating in terms and including in your guidance in the Q4, and how we should think about maybe the cadence of that in 2024? And then also, I'm curious on the market in the US, do you need to have Motiva approval for Flora to see or to really take off? Do physicians typically use the same tissue expander as the implant that they're going to use? Or how does that... What does that market look like in the US?

Juan José Chacón-Quirós (CEO)

Yes, of course. So first of all, you know, just as a reminder, the market for tissue expanders in the US is approximately $180 million, and it has the highest average selling prices in the world. You know, we will start generating revenue from Flora in the US in 2024. And, you know, with the technology that we have, based on science, you know, the unique technology with no magnets, which really changes things for these centers, because now they can, you know, they can do MRIs, they can potentially reduce the amount of radiation oncology. It opens up new opportunities for them in many different ways. So it is an important change for, you know, these centers in the United States. So as we look forward, if you think about, like, what does Flora do?

It creates, you know, this very nice interaction with tissue inside a patient that is recovering from breast cancer. So that tissue is going to define the type of capsule that you have, and thereafter, you know, that capsule can be, you know, the host for an implant that is already, you know, approved for breast reconstruction in the United States or eventually for our Motiva Implants. But there is no reason to believe that, you know, surgeons who understand this would not see it as a benefit, that the initial capsule is created in such a healthy manner by our Flora Tissue Expander.

George Sellers (VP, Equity Research Analyst, Medical Devices)

Okay, that's real. Steps are left after that manufacturing inspection. Have you seen or been given any timeline on when you should expect that?

Juan José Chacón-Quirós (CEO)

No, we have not given any timeline because it is not in our hands. But, you know, we continue to make progress week to week in terms of, you know, the question and answer process with the FDA. Like I said before, we have provided answers to every single one of their questions, now, and, you know, that tells you that the process is coming along quite well. You know, they have not yet scheduled that inspection, but we have, you know, all the questions of Module 3, which is manufacturing, that have been answered. So we expect that to happen hopefully sooner than later.

George Sellers (VP, Equity Research Analyst, Medical Devices)

Okay, that's, that's really helpful. Thank you all again for the time.

Operator (participant)

That is all the time we have for questions today. I will now turn the call back over to Juan José Chacón-Quirós for closing remarks.

Juan José Chacón-Quirós (CEO)

Thank you for joining us on today's call. We will be attending the Jefferies London Healthcare Conference and the Stephens Annual Nashville Conference next week. We look forward to providing our next quarterly update in the new year, and we wish everyone continued good health.

Operator (participant)

This concludes today's conference call. Thank you for your participation, and you may now disconnect.