A-B Tech Comm College Ethicon In-Service

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

• Kurt Prewitt
• Ethicon Products Clinical Representative
• 1-800-888-9234, x1562

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Agenda

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

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ETHICON,INC. a Johnson Johnson Company
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ETHICON, INC.
Johnson Johnson began manufacturing suture
products in 1887 ETHICON, INC., which stands for
Ethical and Confidence, was officially
established as a separate division of Johnson
Johnson in 1949 From the earliest materials to
that of natural materials-GUT SILK to newer,
less reactive synthetic materials, ETHICON has
been at the forefront of technology
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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

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History of Suture Innovation

• 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
• 1947 Nylon
• 1958 MERSILENEpolyester fiber
• 1969 PROLENEpolypropylene Suture
• 1974 VICRYL(polyglactin 910) Suture
• 1976 ETHIBOND polyester Suture
• 1979 Coated VICRYL(polyglactin 910)

1989 PDS II (polydioxanone) Suture 1992 ETHIGUARD
blunt point needle 1993 MONOCRYL
(poliglecaprone 25) Suture 1995 VICRYL Rapide
(polyglactin 910) Suture 1996 Dyed MONOCRYL
(poliglecaprone 25) Suture 1998 DERMABONDTopical
Skin Adhesive 2003 Coated VICRYL Plus
Antibacterial (polyglactin 910) Suture 2006 PDS
and MONOCRYL Plus Antibacterial Sutures

• Trademark
• Data on file, ETHICON, Inc.

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Wound Closure Materials
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Suture Materials

• The following information will review
• Critical Wound Healing Period (CWHP)
• ETHICON Products Absorbable Sutures for
  Short-term, Short- Medium-term,
  Medium-term, and Long-term

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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
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The Critical Wound Healing Period Can Depend on
Various Factors

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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
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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

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

• 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

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Suture Types
Absorbable
Natural
Synthetic
Short-Medium -term
Medium -term
Longer -term
Short -term
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Short-term Wound Support

• Situation in Short-term Wound Support
• Skin mucosa
• Typically emergency procedures
• Typically areas with increased blood flow
• Need Benefit
• Fast-absorbing suture Good clinical
  outcomes
• Rapid loss of strength/mass
• Good knot formation/snug down

Procedure Example Episiotomy Perineal Repair
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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.

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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

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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 Benefit
• High initial strength Good Clinical
  Outcomes
• Good cosmesis
• Good handling passage through tissue
• Good knot formation/snug down
• Low reactivity

Procedure Example Plastic Surgery
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MONOCRYL (polyglecaprone 25) Suture

• 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

• Trademark
• Data on file, ETHICON, INC

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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 Benefit
• Consistent strength around the CWHP Good
  clinical outcomes
• Good handling passage through tissue
• Good knot formation/snug down
• Low reactivity

Procedure Example General Closure
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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.

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The evolution of the Worlds 1 Suture
2003
2003
28 day claim 25
2000
Vegetable-based calcium stearate
1996
21 day claim 50
1988
21 day claim improves to 40
1983
VICRYL Suture 2.0 dpf 21 day claim is 20
1979
VICRYL Suture Coating-Polyglactin 370 and calcium
stearate
1977
Improved VICRYL Suture 3.5dpf
1974
Uncoated VICRYL Suture launched 5dpf
Trademark Data on file, ETHICON, INC. .
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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 Benefit
• 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
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PDS II Suture (polydioxanone) suture

• 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

• Trademark
• Data on file, ETHICON, INC.

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Suture Materials

• NON-ABSORBABLE SUTURE
• SPECIALTY FOCUS

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Suture Types
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PROLENE (polypropylene) Suture
SYNTHETIC Minimal tissue reaction even in the
presence of infection MONOFILAMENT Smooth
passage through delicate tissue POLYPROPYLEN
E 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.
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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.
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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.
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ETHILON (nylon) suture
MONOFILAMENT Smooth, easy passage through
tissue NYLON Less tissue reaction Provide
s 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.
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Specialty Focus

• Plastic Surgery
• Focus on..
• MONOCRYL suture
• ETHILON suture
• Cardiovascular Surgery
• Focus on..
• PROLENE suture
• ETHIBOND EXCEL suture

Trademark Data on file, ETHICON, INC.
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Plastic Surgery

• Situation in plastic surgery
• Cosmetic results
• Aesthetic outcomes
• Consistent performance (suturing is signature)
• Varying degrees of tissue strength/ length of
  incisions
• Need Benefit
• Low reactivity Good clinical outcomes
• Pliability smooth passage through tissue
• Good cosmesis
• Monofilament preferred

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MONOCRYL Suture Advantages for Plastic Surgery

• Ease of passage through tissue
• Monofilament
• Pliability/ surgical hand
• Excellent cosmesis
• Good knot security tie down
• Attached to P, PS and PC series needles
• Some of the best surgical needles in the
  world

• Trademark
• Data on file, ETHICON, INC.

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ETHILON Suture

• Pliabilized Enhances handling in cosmetic
  surgery
• Good cosmesis
• Attached to PS and PC series needles

• Trademark
• Data on file, ETHICON, INC.

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NUROLON Nylon Suture

• Specially made for neurological surgery
• Handles like silk
• Higher strength and less tissue reaction than silk

• TTrademark
• Data on file, ETHICON, INC.

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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

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Cardiovascular Surgery

• Situation in C.A.B.G.
• More diseased vessels
• Typically smaller vessels
• Harder to access
• Often suturing on beating heart
• Need Benefit
• Smooth passage through tissue Good Clinical
  Outcomes
• Good knot tensile strength Preferred
  performance handling
• Good knot formation/snug down
• Low reactivity
• Consistent performance

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PROLENE Suture

• Used in 9 out of every 10 CABG procedures
• Controlled linear elongation the early warning
  system manufactured into every strand
• Unique knotting properties plastic knot
  deformity
• Smooth tissue passage
• Rigorous manufacturing process to ensure truly
  consistent sutures
• Special raw material certification process
• 35 years of market leadership

• Trademark
• Data on file, ETHICON, INC.

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Manufacturing Process

• Special Material Certification Process
• Raw material goes through rigorous evaluation and
  selection process
• Product is stored under tightest of conditions
  until use
• Meticulous extrusion process to turn raw material
  into strands of suture
• Numerous quality checks at every manufacturing
  stage
• Results in product which has unrivalled quality
  and consistency

Trademark Data on file, ETHICON, INC.
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Size 8-0 PROLENE Suture

• 8-0 suture is frequently used for IMA-LAD
  anastomosis and also fine distal vein grafts
• 8-0 PROLENE suture is a true 8-0, in that it
  falls within the USP specifications for 8-0
  suture sizing
• Both 8-0 SURGIPRO II and DEKLENE II are
  significantly oversized up to 20 - and fall
  within the specifications for a 7-0 suture
• 7-0 PROLENE suture is significantly stronger than
  both the 8-0 SURGIPRO II and 8-0 DEKLENE II

• Trademark
• Data on file, ETHICON, INC.
• Competitive Trademark Syneture

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Valve Surgery

• Need
• High tensile strength
• Smooth passage through tissue
• Excellent handling
• Secure knot tie down
• Consistent tissue reaction

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ETHIBOND Excel Suture

• 30 stronger than TICRON at size 2-0
• Unique braiding construction provides strong
  supple consistent suture
• Proprietary coating allows for smooth tissue
  passage and smooth knot tie-down (no chattering)
• Superior knot security

• Trademark
• Data on file, ETHICON, INC.
• Competitive Trademark Syneture

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Trademark
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Advanced Needle Technology
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ETHICON Products Box
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ETHICON Products Advanced Needle Technology
Superior Alloy
A.N.T.
Superior Geometry
Superior Coating
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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 ETHICONs
  Advanced Needle Technology

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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
• 121 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..

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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

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Coating - What is MultiPass?

• Proprietary new needle coating
• Provides superior needle penetration performance
  consistency
• Pass after Pass
• Needle to Needle
• Through 30 needle passes

1st pass is not improved 5th, 10th, 20th and
30th are!

• Trademark
• Data on file, ETHICON, INC.

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Needles Shapes


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Needles Types


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SPECIALTY FOCUS

• Plastic cosmetic skin closure
• C.V. vascular anastomosis valve surgery

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Focus on Plastic Surgery

• Procedures are changing
• Growth of body contouring
• Cosmetic procedures are increasing
• Cosmetic outcomes more important than ever across
  all specialties
• Need
• Requires consistent needle pass gt30x
• Requires resistance to bending
• Requires penetration performance pass after pass
• 
  

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Focus on Plastic Surgery Needles

• What does Advanced Needle Technology deliver in
  plastic surgery?
• Alloy ETHALLOY alloy
• Geometry PRIME geometry
• Coating MultiPass needle coating

• Trademark
• Data on file, ETHICON, INC..

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ETHICON Products Packaging

• ETHICON Products continuously innovates packaging
  in consideration of
• Less environmental waste
• Easy and safe access
• Smooth dispensing
• Package memory

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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
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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

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New Innovations
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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

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CONTRIBUTING FACTORS

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

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ROLE OF THE IMPLANT

• Three Key Factors
• Less Bacteria Required
• Microorganisms Can Colonize and Spread
• Biofilm Formation
• The Key - Preventing Bacteria Colonization

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

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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

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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.
• .

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Not all adhesives are created equal
DERMABOND
INDERMIL

• Flexible 8-carbon side chain
• 2X wound burst strength
• 4X breaking strength
• High viscosity Stays put
• May not require a bandage
• Patient showers immediately
• No refrigeration required
• Clinically proven to close incisions up to 69 cm

• Brittle 4-carbon side chain
• Lower closure strength
• Lower breaking strength
• Low viscosity
• Bandage required for 48 hours
• No showering for 48 hours
• Refrigeration required
• Clinically proven to close incisions up to 8 cm

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Value of ETHICON Products Suture

• Economics of conversion
• Suture in-services, PROF ED, grand rounds,
  education focus
• Inventory Management
• Quality, consistency, innovation
• It is more than just Suture!

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ETHICON Value Above Price

• New procedures critical products released to
  improve procedural outcomes.
• Quality hospital programs to reduce cost.
• Physician signatures/letters supporting ETHICON
  Products.

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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).

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A- B Tech Comm College

• Thank you for your attention!
• Questions ?
• Kurt Prewitt
• Ethicon Products Clinical Representative
• 1-800-888-9234, x1562