CONFIDENTIAL AB Tech Comm College Ethicon InService Sutures

CONFIDENTIAL A-B Tech Comm College Ethicon In-Service – Sutures / Dermabond Kurt Prewitt Ethicon Products Clinical Representative 1 -800 -888 -9234, x 1562 <SECTIONS>

CONFIDENTIAL Agenda • Ethicon • Sutures – Absorbable and Non-Absorbable – Needles • New Innovations – Vicryl Plus – Dermabond Pro. Pen <SECTIONS>

CONFIDENTIAL 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 <SECTIONS>

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

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

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

CONFIDENTIAL 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 Epidermis Dermis Wound Subcutaneous (Fat) Slow Healing Epidermis Dermis Subcutaneous (Fat) Fascia <SECTIONS> Cutting Needles Taper Needles

CONFIDENTIAL ETHICON Products Box clearly distinguishes the type of suture and needle information • Code • Suture size • Product name • Suture length • Needle size • Type of needle • Quantity <SECTIONS>

CONFIDENTIAL Suture Types Absorbable Natural Monofilament Short -term Non-Absorbable Synthetic Natural Monofilament Braided Short-Medium -term Longer -term <SECTIONS> Synthetic Braided

CONFIDENTIAL Suture Summary Absorbable Non-Absorbable • Braided – Vicryl Plus – Vicryl Rapide – – – • Monofilament – – – Monocryl PDS II Plain Gut - Natural Chromic Gut - Natural Fast Absorbing Gut - Natural Silk - Natural Cotton - Natural Nurolon Mersilene Ethibond Excel • Monofilament <SECTIONS> – Prolene – Ethilon – Stainless Steel - Natural

CONFIDENTIAL Suture Types Absorbable Natural Monofilament Short -term Synthetic Braided Monofilament Short-Medium -term <SECTIONS> Braided Longer -term

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

CONFIDENTIAL ETHICON Products Gut Suture All 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. <SECTIONS>

CONFIDENTIAL Coated VICRYL RAPIDE* (polyglactin 910) Suture 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 • Trademark * Data on file, ETHICON, INC <SECTIONS>

CONFIDENTIAL 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 Need § • • High initial strength Good cosmesis Good handling & passage through tissue Good knot formation/snug down Low reactivity Benefit · Good Clinical Outcomes Procedure Example: Plastic Surgery <SECTIONS>

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

CONFIDENTIAL 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 Need • • Consistent strength around the CWHP Good handling & passage through tissue Good knot formation/snug down Low reactivity Benefit · Good clinical outcomes Procedure Example: General Closure <SECTIONS>

CONFIDENTIAL Coated VICRYL* (polyglactin 910) Suture 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 • Trademark Data on file, ETHICON, INC. <SECTIONS>

CONFIDENTIAL 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 Need • • Strength beyond the CWHP of 21 days Good handling & passage through tissue Good knot formation/snug down Low reactivity Benefit · Good clinical outcomes Procedure Example: Body Contouring <SECTIONS>

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

CONFIDENTIAL Suture Types Non-Absorbable Natural Monofilament Synthetic Braided Monofilament <SECTIONS> Braided

CONFIDENTIAL 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 PROCESS Highly controlled Numerous quality checks Controlled linear elongation Consistent suture, strand- to-strand *Trademark Data on file, ETHICON, INC. <SECTIONS>

CONFIDENTIAL 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 COATING Smooth knot tie-down Excellent handling properties Unmatched polyester knot security *Trademark Data on file, ETHICON, INC. <SECTIONS>

CONFIDENTIAL 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. <SECTIONS>

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

CONFIDENTIAL 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. <SECTIONS>

CONFIDENTIAL 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 <SECTIONS>

CONFIDENTIAL Advanced Needle Technology <SECTIONS>

CONFIDENTIAL ETHICON Products Box <SECTIONS>

CONFIDENTIAL 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 <SECTIONS>

CONFIDENTIAL Focus on Needle Geometry Provides the appropriate penetration performance for surgical indication and maximizes ease of handling during surgery GEOMETRY TIP BODY Various designs for surgical indication Designed for ease of use • PRIME* cutting – for skin closure • BV Taper – vascular anastomosis • ETHIGUARD* Blunt – safety needles • CS Ultima* – spatulated ophthalmic • V-Series – penetrating taper tough tissue • 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 • Trademark Data on file, ETHICON, INC. . <SECTIONS>

CONFIDENTIAL 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 <SECTIONS>

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

CONFIDENTIAL Needles Shapes ¼ Circle ½ Circle 3/8 Circle 5/8 Circle <SECTIONS> ½ Curve Straight

CONFIDENTIAL Needles Types Taper Point Needle ETHIGUARD* Blunt Point Needle Conventional Cutting Reverse Cutting <SECTIONS>

CONFIDENTIAL 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 <SECTIONS>

CONFIDENTIAL New Innovations <SECTIONS>

CONFIDENTIAL 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 <SECTIONS>

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

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

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

CONFIDENTIAL 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 <SECTIONS>

CONFIDENTIAL 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 <SECTIONS>

CONFIDENTIAL Topical Adhesives 1. Competes with sutures and staples for skin closure 2. Strong as 4 -0 suture within 3 minutes 3. Microbial barrier 4. Cosmesis 5. An occlusive dressing 6. Fast and easy 7. Patient satisfaction and comfort 8. Close incisions up to 69 cm 9. Patient friendly – Shower immediately, min post-op care • Trademark Data on file, ETHICON, INC. <SECTIONS>

CONFIDENTIAL 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). <SECTIONS>

CONFIDENTIAL A- B Tech Comm College Thank you for your attention! Questions ? Kurt Prewitt Ethicon Products Clinical Representative 1 -800 -888 -9234, x 1562 <SECTIONS>