# EDGAR Filing Document

**Accession Number:** 0001688757
**File Stem:** 0001742429-23-000003
**Filing Date:** 2023-1
**Character Count:** 10298
**Document Hash:** 3cba406101f1c850ca94fbeae6104010
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0001742429-23-000003.hdr.sgml**: 20230120

**ACCESSION NUMBER**: 0001742429-23-000003

**CONFORMED SUBMISSION TYPE**: SC 13G/A

**PUBLIC DOCUMENT COUNT**: 1

**FILED AS OF DATE**: 20230120

**DATE AS OF CHANGE**: 20230120

**SUBJECT COMPANY**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** ESTABLISHMENT LABS HOLDINGS INC.
- **CENTRAL INDEX KEY:** 0001688757
- **STANDARD INDUSTRIAL CLASSIFICATION:** ORTHOPEDIC, PROSTHETIC & SURGICAL APPLIANCES & SUPPLIES [3842]
- **IRS NUMBER:** 981436377

**FILING VALUES:**
- **FORM TYPE:** SC 13G/A
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 005-90783
- **FILM NUMBER:** 23541611

**BUSINESS ADDRESS:**
- **STREET 1:** PO BOX 3140, COMMERCE HOUSE
- **STREET 2:** WICKHAMS CAY 1, ROAD TOWN
- **CITY:** TORTOLA
- **STATE:** D8
- **ZIP:** VG1110
- **BUSINESS PHONE:** 50624342400

**MAIL ADDRESS:**
- **STREET 1:** PO BOX 3140, COMMERCE HOUSE
- **STREET 2:** WICKHAMS CAY 1, ROAD TOWN
- **CITY:** TORTOLA
- **STATE:** D8
- **ZIP:** VG1110
**FILED BY**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** Chacon Quiros Juan Jose
- **CENTRAL INDEX KEY:** 0001742429

**FILING VALUES:**
- **FORM TYPE:** SC 13G/A

**MAIL ADDRESS:**
- **STREET 1:** C/O MOTIVA USA LLC
- **STREET 2:** 16192 COASTAL HIGHWAY
- **CITY:** LEWES
- **STATE:** DE
- **ZIP:** 19958

**FORMER COMPANY:**
- **FORMER CONFORMED NAME:** Quiros Juan Jose Chacon
- **DATE OF NAME CHANGE:** 20180601

**UNITED STATES**

**SECURITIES AND EXCHANGE COMMISSION**

**Washington, D.C. 20549**

**SCHEDULE 13G**

**Under the Securities Exchange Act of 1934**

**(Amendment No. 4)\***

---

| |
|:---|
| Establishment Labs Holdings Inc. |
| (Name of Issuer) |
| Common Shares, no par value |
| (Title of Class of Securities) |
| G31249 108 |
| (CUSIP Number) |
| December 31, 2022 |
| (Date of Event Which Requires Filing of this Statement) |

---

Check the appropriate box to designate the rule pursuant to which this Schedule is filed:

---

| | |
|:---|:---|
| ◻ | Rule 13d-1(b) |
| ◻ | Rule 13d-1(c) |
| ⌧ | Rule 13d-1(d) |

---

\*The remainder of this cover page shall be filled out for a reporting person's initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter the disclosures provided in a prior cover page.

The information required in the remainder of this cover page shall not be deemed to be "filed" for the purpose of Section 18 of the Securities Exchange Act of 1934 ("Act") or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however, see the Notes).

------

---

| | |
|:---|:---|
| <br>CUSIP No. G31249 108  | <br>CUSIP No. G31249 108  |
| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;1. Names of Reporting Persons.<br>Juan Jose Chacon Quiros  | &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;1. Names of Reporting Persons.<br>Juan Jose Chacon Quiros  |
| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;2. Check the Appropriate Box if a Member of a Group (See Instructions)<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(a) ◻<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(b) ◻ | &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;2. Check the Appropriate Box if a Member of a Group (See Instructions)<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(a) ◻<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(b) ◻ |
| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;3. SEC Use Only | &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;3. SEC Use Only |
| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;4. Citizenship or Place of Organization Costa Rica | &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;4. Citizenship or Place of Organization Costa Rica |
| Number of Shares Beneficially Owned by Each Reporting Person With: | 5. Sole Voting Power 1,401,132 (See Item 4(a) below)  |
| Number of Shares Beneficially Owned by Each Reporting Person With: | 6. Shared Voting Power 0  |
| Number of Shares Beneficially Owned by Each Reporting Person With: | 7. Sole Dispositive Power 1,401,132 (See Item 4(a) below)  |
| Number of Shares Beneficially Owned by Each Reporting Person With: | 8. Shared Dispositive Power 0  |
| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;9. Aggregate Amount Beneficially Owned by Each Reporting Person 1,401,132 (See Item 4(a) below)  | &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;9. Aggregate Amount Beneficially Owned by Each Reporting Person 1,401,132 (See Item 4(a) below)  |
| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;10. Check if the Aggregate Amount in Row (9) Excludes Certain Shares (See Instructions)  | &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;10. Check if the Aggregate Amount in Row (9) Excludes Certain Shares (See Instructions)  |
| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;11. Percent of Class Represented by Amount in Row (9) 5.8% (See Item 4(b) below)  | &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;11. Percent of Class Represented by Amount in Row (9) 5.8% (See Item 4(b) below)  |
| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;12. Type of Reporting Person (See Instructions) | &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;12. Type of Reporting Person (See Instructions) |
| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;IN  | &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;IN  |

---

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**Item 1(a) Name of Issuer:**

**&nbsp;&nbsp;&nbsp;&nbsp;**Establishment Labs Holdings Inc.

**Item 1(b) Address of Issuer's Principal Executive Offices:**

**&nbsp;&nbsp;&nbsp;&nbsp;**Building B15 and 25

&nbsp;&nbsp;&nbsp;&nbsp;Coyol Free Zone

&nbsp;&nbsp;&nbsp;&nbsp;Alajuela

&nbsp;&nbsp;&nbsp;&nbsp;Costa Rica

**Item 2 (a) Name of Person Filing:**

**&nbsp;&nbsp;&nbsp;&nbsp;**Juan Jose Chacon Quiros

**Item 2 (b) Address of Principal Business Office or, if none, Residence:**

&nbsp;&nbsp;&nbsp;&nbsp;c/o Establishment Labs Holdings Inc.

&nbsp;&nbsp;&nbsp;&nbsp;Building B15 and 25

&nbsp;&nbsp;&nbsp;&nbsp;Coyol Free Zone

&nbsp;&nbsp;&nbsp;&nbsp;Alajuela

&nbsp;&nbsp;&nbsp;&nbsp;Costa Rica

**Item 2 (c) Citizenship:**

&nbsp;&nbsp;&nbsp;&nbsp;Juan Jose Chacon Quiros is a citizen of Costa Rica.

**Item 2 (d) Title of Class of Securities:**

&nbsp;&nbsp;&nbsp;&nbsp;Common Shares, no par value

**Item 2 (e) CUSIP Number:**

&nbsp;&nbsp;&nbsp;&nbsp;G31249 108

**Item 3.&nbsp;&nbsp;&nbsp;&nbsp;If this statement is filed pursuant to §§240.13d-1(b) or 240.13d-2(b) or (c), check whether the person filing is a:** 

Not applicable.

**Item 4.** &nbsp;&nbsp;&nbsp;&nbsp;**Ownership**

&nbsp;&nbsp;&nbsp;&nbsp;(a)&nbsp;&nbsp;&nbsp;&nbsp;Amount beneficially owned:&nbsp;&nbsp;&nbsp;&nbsp;

As of December 31, 2022, (i) 194,240 Common Shares were held of record by Juan Jose Chacon Quiros, (ii) Mr. Chacon Quiros has the right to acquire 78,628 Common Shares within 60 days of December 31, 2022 upon the exercise of stock options and (iii) 1,128,264 Common Shares were held of record by Sariel LLC, of which Mr. Chacon Quiros is a shareholder and over which he has voting and dispositive power.

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&nbsp;&nbsp;&nbsp;&nbsp;(b)&nbsp;&nbsp;&nbsp;&nbsp;Percent of class: 5.8%

The ownership percentage above is calculated based on 24,342,327 Common Shares outstanding as of November 8, 2022, as reported in the Issuer's Form 10-Q filed with the Securities and Exchange Commission on November 8, 2022.

&nbsp;&nbsp;&nbsp;&nbsp;(c)&nbsp;&nbsp;&nbsp;&nbsp;Number of shares as to which the person has:

**&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;**(i)&nbsp;&nbsp;&nbsp;&nbsp;Sole power to vote or direct the vote:&nbsp;&nbsp;&nbsp;&nbsp;1,401,132 shares

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(ii)&nbsp;&nbsp;&nbsp;&nbsp;Shared power to vote or direct the vote:&nbsp;&nbsp;&nbsp;&nbsp; 0 shares

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(iii)&nbsp;&nbsp;&nbsp;&nbsp;Sole power to dispose or to direct the disposition of:&nbsp;&nbsp;&nbsp;&nbsp;1,401,132 shares

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(iv)&nbsp;&nbsp;&nbsp;&nbsp;Sole power to dispose or to direct the disposition of:&nbsp;&nbsp;&nbsp;&nbsp;0 shares

**Item 5.** &nbsp;&nbsp;&nbsp;&nbsp;**Ownership of 5 Percent or Less of a Class**

&nbsp;&nbsp;&nbsp;&nbsp;Not applicable.

**Item 6.** &nbsp;&nbsp;&nbsp;&nbsp;**Ownership of More than 5 Percent on Behalf of Another Person**

&nbsp;&nbsp;&nbsp;&nbsp;Not applicable.

**Item 7.** &nbsp;&nbsp;&nbsp;&nbsp;**Identification and Classification of the Subsidiary Which Acquired the Security Being Reported on By the Parent Holding Company or Control Person**

&nbsp;&nbsp;&nbsp;&nbsp;Not applicable.

**Item 8.** &nbsp;&nbsp;&nbsp;&nbsp;**Identification and Classification of Members of the Group**

&nbsp;&nbsp;&nbsp;&nbsp;Not applicable.

**Item 9.** &nbsp;&nbsp;&nbsp;&nbsp;**Notice of Dissolution of Group**

&nbsp;&nbsp;&nbsp;&nbsp;Not applicable.

**Item 10.** &nbsp;&nbsp;&nbsp;&nbsp;**Certifications**

&nbsp;&nbsp;&nbsp;&nbsp;Not applicable.

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**SIGNATURES**

After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct.

Date: January 20, 2023

<u>/s/ Juan Jose Chacon Quiros&nbsp;&nbsp;&nbsp;&nbsp;</u>

Juan Jose Chacon Quiros

<br>