A-B Tech Comm College Ethicon In-Service – Sutures / Dermabond

1. A-B Tech Comm College Ethicon In-Service – Sutures / Dermabond Kurt Prewitt Ethicon Products Clinical Representative 1-800-888-9234, x1562

2. Agenda • Ethicon • Sutures • Absorbable and Non-Absorbable • Needles • New Innovations • Vicryl Plus • Dermabond ProPen

3. Definitions • Suture • Term for material used to align severed body tissue together; to hold in place while healing occurs • Ligature or tie • A strand of suture material that is used to: • Tie off blood vessels • Prevent hemorrhage/bleeding • Isolate tissue while excising

4. History of Suture Innovation 1989PDS II* (polydioxanone) Suture 1992ETHIGUARD*blunt point needle 1993MONOCRYL* (poliglecaprone 25) Suture 1995VICRYL Rapide* (polyglactin 910) Suture 1996Dyed MONOCRYL* (poliglecaprone 25) Suture 1998DERMABOND*Topical Skin Adhesive 2003Coated VICRYL Plus* Antibacterial (polyglactin 910) Suture 2006 PDS and MONOCRYL Plus* Antibacterial Sutures 2000 BC Ancient Egyptians 460 BC – 1865 AD Cauterize to ligation 1887 Silk and Cat Gut 1930s Commercial manufacturing 1940s Sterilization and uniformity 1950s Individualized packaging 1947Nylon 1958MERSILENE*polyester fiber 1969PROLENE*polypropylene Suture 1974VICRYL*(polyglactin 910) Suture 1976ETHIBOND* polyester Suture 1979Coated VICRYL*(polyglactin 910) • Trademark • Data on file, ETHICON, Inc.

5. Critical Wound Healing Period Skin Mucosa Subcutaneous Peritoneum Fascia 5-7 Days 5-7 Days 7-14 Days 7-14 Days 14-28 Days 0 5 7 14 21 28 days Tissue Healing Times

6. Age • Weight • Nutrition • Dehydration • Blood Supply • Immune response • Chronic diseases • Localized infection • Diabetes • History of Radiation Therapy The Critical Wound Healing Period Can Depend on Various Factors

7. Suture Sizes • Sizes range from 7 (Largest) to 11-0 (Smallest) • Size 7-0 is the size of a human hair • Example – General Closure • Fascia – Size 1 to 2-0 • Fat – Size 2-0 to 4-0 • Skin – Size 3-0 to 5-0 Fast Healing Wound Cutting Needles Epidermis Epidermis Dermis Dermis Taper Needles Subcutaneous (Fat) Subcutaneous (Fat) Fascia Fascia Slow Healing

8. ETHICON Products Box • Box clearly distinguishes the type of suture and needle information • Code • Suture size • Product name • Suture length • Needle size • Type of needle • Quantity

9. Suture Types Absorbable Non-Absorbable Natural Synthetic Natural Synthetic Monofilament Braided Braided Monofilament Short -term Short-Medium -term Medium -term Longer -term

10. Braided Vicryl Vicryl Plus Vicryl Rapide Monofilament Monocryl PDS II Plain Gut - Natural Chromic Gut - Natural Fast Absorbing Gut - Natural Braided Silk - Natural Cotton - Natural Nurolon Mersilene Ethibond Excel Monofilament Prolene Ethilon Stainless Steel - Natural Suture Summary Non-Absorbable Absorbable

11. Braided Braided Monofilament Monofilament Suture Types Absorbable Natural Synthetic Short -term Short-Medium -term Medium -term Longer -term

12. Short-term Wound Support • Situation in Short-term Wound Support • Skin & mucosa • Typically emergency procedures • Typically areas with increased blood flow • NeedBenefit • Fast-absorbing suture ·Good clinical outcomes • Rapid loss of strength/mass • Good knot formation/snug down Procedure Example: Episiotomy & Perineal Repair

13. ETHICON Products Gut SutureAll Gut is not created equal • ETHICON Products Surgical Gut sutures are manufactured from almost 100% pure collagen: (i.e. small intestine of sheep or serosa of cattle) Quality in raw material which minimizes tissue reactions. • TRU-GAUGING is an exclusive ETHICON process which produces the most uniform diameter possible: No fraying of the suture after tie-down • Buffered CHROMICIZING the entire suture is an exclusive ETHICON process which minimizes tissue irritation.

14. SYNTHETIC Predictable absorption Minimal tissue reaction FAST ABSORPTION No foreign body after 6 weeks Superficial sutures brush off after 7-10 days BRAIDED Good handling & knotting Initial strength greater than nylon & gut suture COATING Smooth passage through tissue. Easy knot adjustment For delicate repairs the comfort of a synthetic alternative to gut suture Coated VICRYL RAPIDE* (polyglactin 910) Suture • Trademark • * Data on file, ETHICON, INC

15. Short-Medium-term Wound Support • Situation in Short-Medium-term Wound Support • Skin, mucosa, subcuticular • Typically cosmetic surgery cases • Typically areas with increased blood flow NeedBenefit • High initial strength ·Good Clinical Outcomes • Good cosmesis • Good handling & passage through tissue • Good knot formation/snug down • Low reactivity Procedure Example: Plastic Surgery

16. SYNTHETIC Predictable absorption Minimal tissue reaction MONOFILAMENT Smooth passage through tissue POLIGLECAPRONE 25 Excellent handling characteristics and pliability Excellent knot security Monofilament pliability unprecedented among synthetic absorbable suture MONOCRYL* (polyglecaprone 25) Suture • Trademark • * Data on file, ETHICON, INC

17. Medium-term Wound Support • Situation in Medium-term Wound Support • All tissue layers that align with the critical wound healing period of 21-28 days • All tissue types NeedBenefit • Consistent strength around the CWHP ·Good clinical outcomes • Good handling & passage through tissue • Good knot formation/snug down • Low reactivity Procedure Example: General Closure

18. SYNTHETIC Predictable absorption Minimal tissue reaction ABSORBABLE No foreign body after 56-70 days Strength in the critical wound healing time with new claim of 25% BSR at 28 days BRAIDED Strong good handling & knotting COATING Smooth passage through tissue. Minimal tissue trauma Unique coating enables knot adjustability Unequaled strength from the worlds #1 Suture Coated VICRYL* (polyglactin 910) Suture • Trademark • Data on file, ETHICON, INC.

19. Longer- term wound support • Situation in Longer-term Wound Support • Tissue that requires extended support • Friable tissue • Slow healing tissue/ compromised patients • Typically fascia tissue NeedBenefit • Strength beyond the CWHP of 21 days ·Good clinical outcomes • Good handling & passage through tissue • Good knot formation/snug down • Low reactivity Procedure Example: Body Contouring

20. SYNTHETIC Predictable absorption Minimal tissue reaction MONOFILAMENT Smooth passage through tissue Initial strength greater than nylon & gut suture POLYDIOXANONE Prolonged wound support High initial strength Good handling characteristics Knot security PRODUCT OFFERING Looped suture for speed and security of long incision fascia closure Strongest synthetic absorbable suture for extended wound support PDS II * Suture (polydioxanone) suture • Trademark • Data on file, ETHICON, INC.

21. Non-Absorbable Natural Synthetic Braided Braided Monofilament Monofilament Suture Types

22. PROLENE* (polypropylene) Suture SYNTHETIC Minimal tissue reaction even in the presence of infection MONOFILAMENT Smooth passage through delicate tissue POLYPROPYLENE Will not fatigue with flexing Provides permanent wound support Unique knotting properties MANUFACTURING Highly controlled PROCESS Numerous quality checks Controlled linear elongation Consistent suture, strand- to-strand *Trademark Data on file, ETHICON, INC.

23. ETHIBOND EXCEL* (polyester) Suture SYNTHETIC Minimal tissue reaction BRAIDED 30% Stronger than leading competitor (size 2/0) Good handling & knotting 15% stronger than ever before Central core provides strong suture POLYESTER Provides permanent wound support POLYBUTILATE Smooth knot tie-down COATING Excellent handling properties Unmatched polyester knot security *Trademark Data on file, ETHICON, INC.

24. PERMA-HAND* Silk Suture BRAIDED Excellent handling and knotting characteristics WAX COATING Improved surface qualities Reduces capillarity INDICATIONS Used in a wide variety of surgical procedures *Trademark Data on file, ETHICON, INC.

25. ETHILON* (nylon) suture MONOFILAMENT Smooth, easy passage through tissue NYLON Less tissue reaction Provides long term wound support PLIABILIZED Ease of handling OFFERING Less package memory INDICATIONS Used in a wide variety of procedures Fine sizes specifically for use in ophthalmic and microsurgery *Trademark Data on file, ETHICON, INC.

26. NUROLON* Nylon Suture • Specially made for neurological surgery • Handles like silk • Higher strength and less tissue reaction than silk • T*Trademark • Data on file, ETHICON, INC.

27. Cotton and Steel • Cotton • Natural cellulose multifilament fiber • Weakest of non-absorbable materials, but gains strength when wet • Used for ligating and suturing • No advantages over silk • Steel • Inert with high tensile strength • Used for sternum closure, orthopedics, neurosurgery • May be used in presence of infection • Difficult to handle and tie. May damage tissue. • Be Careful! Keep straight, double glove, use wire cutters

28. Advanced Needle Technology

29. ETHICON Products Box

30. The Anatomy of the Ideal Surgical Needle • Three key factors make up the ideal needle: • Alloy • Geometry – tip and body • Coating • The combination of these attributes is ETHICON’s Advanced Needle Technology

31. Focus on Needle Geometry Provides the appropriate penetration performance for surgical indication and maximizes ease of handling during surgery GEOMETRY TIP BODY • Designed for ease of use • Needle Ribs – stability in needle • holder • BV – rounded geometry for arming • flexibility • 12:1 taper ratio – smooth passage, • improved penetration • Laser Drilled – smooth needle – • suture transition • Various designs for surgical indication • PRIME* cutting – for skin closure • BV Taper – vascular anastomosis • ETHIGUARD* Blunt – safety needles • CS Ultima* – spatulated ophthalmic • V-Series – penetrating taper tough tissue • Trademark • Data on file, ETHICON, INC..

32. Geometry-What is Prime? Less mass than typical reverse cutting needle = improved penetration and control • An exclusive needle tip design that provides • Precise placement • Smoother repeated passage • Better control • Less tissue trauma

33. Proprietary new needle coating Provides superior needle penetration performance consistency Pass after Pass Needle to Needle Through 30 needle passes Coating - What is MultiPass*? 1st pass is not improved 5th, 10th, 20th and 30th are! • *Trademark • Data on file, ETHICON, INC.

34. ¼ Circle 3/8 Circle ½ Curve 5/8 Circle Straight ½ Circle Needles Shapes

35. Taper Point ETHIGUARD* Needle Blunt Point Needle Conventional Reverse Cutting Cutting Needles Types

36. PROLENE* suture Packaging Innovation Paper Folder 1990 • Needles held in place by suture • Needle separation Door Relay 1992 • One step opening (no paper tear tab) • Needles held in park • Circulating & scrub nurse verify needle count • Recyclable plastic tray Zipper Relay 2000 • Automated process (More Consistent Handling of needles & sutures) • Enhanced needle separation * Trademark

37. New Innovations

39. Surgical Site Infection (SSI) FACTS • 27 Million Procedures in the US • 2%-3% Infection Rates • 675,000 SSIs • 66% Confined to Incision • Staph a, Staph e, MRSA, MRSE

40. CONTRIBUTING FACTORS • OR • Procedure • Technique • Patient • Implants • And others

41. ROLE OF THE IMPLANT • Three Key Factors • Less Bacteria Required • Microorganisms Can Colonize and Spread • Biofilm Formation • The Key - Preventing Bacteria Colonization

42. VICRYL Plus Inhibits Bacterial Colonization Renders the suture neutral Potentially eliminates it from the SSI Equation

43. FACTS TO REMEMBER • VICRYL Plus Antibacterial Suture Creates a Zone of Inhibition • VICRYL Plus Suture is Bacteriocidal • VICRYL Plus Suture Is Effective Against Staph a, Staph e, MRSA, MRSE • VICRYL Plus Suture Is Designed to Be Used Everywhere You Use VICRYL Suture

44. FACTS TO REMEMBER • Medical Implants, Such As Sutures, Do Not Cause Infection • SSI Common Contributing Factors • Patient Profile • Surgical Technique • Surgical Environment • The Procedure Itself • Medical Implants

45. Topical Adhesives • Competes with sutures and staples for skin closure • Strong as 4-0 suture within 3 minutes • Microbial barrier • Cosmesis • An occlusive dressing • Fast and easy • Patient satisfaction and comfort • Close incisions up to 69 cm • Patient friendly – Shower immediately, min post-op care • Trademark • Data on file, ETHICON, INC. • .

46. ETHICON Products: Value Above Price • Over 300 sales reps hired and trained to service all hospital customers. • Clinicians trained on new products / procedures. • Suture utilization/standardization programs. (i.e., Inventory programs, returns, in-services) • Key customer events (ie: symposiums, plant educational events, key customer visits).

47. A- B Tech Comm College Thank you for your attention! Questions ? Kurt Prewitt Ethicon Products Clinical Representative 1-800-888-9234, x1562