Aroa Biosurgery Limited (ARX) Earnings Call Transcript & Summary

Welcome to Aroa BioSurgery's Investor Webinar and Q&A following the company's half year results announcement released this morning. [Operator Instructions] There will be a presentation lasting for approximately 20 minutes followed by Q&A session. Following presentation of results, we will be joined by leading U.S. surgeon, Dr. Anthony LaLama, who will discuss the clinical challenges of lower extremity reconstruction and the efficacy of AROA ECM products in achieving tissue coverage and closure for these patients. The webinar will conclude at approximately 10 a.m. Australian Eastern Standard Time. [Operator Instructions] Please note that this session is being recorded. On behalf of Aroa today, we have Brian Ward, Founder; and James Agnew, CFO. I will now hand over to Brian and James. Please go ahead.

Thank you, Sarah, and welcome to everybody, and thank you for joining this morning's webinar for our half year results. I'm going to talk about sort of three parts in my presentation. So the first part, just a quick overview of the company for those investors that are new to the company. I'm then going to talk a little bit about what we learned with Myriad, over developing the clinical evidence for that product. And then going to move on and summarize our half year financial results. So just in terms of an overview and what we're trying to do as a company. We're very focused on unlocking regenerative healing for everybody and with our platform technology, we think that we're very well placed to do that. And the reason for that is that the technology has world-leading outcomes, and we'll talk about that, unmatched value for hospitals and the potential to have widespread impact for a lot of patients. This is a well-established high-growth soft tissue generation company. We have four families of products that we are commercializing predominantly in the U.S., selling them to hospitals, predominantly in the operating room, all based on our AROA ECM platform. The total addressable market for these products in excess of $3 billion. We sell through -- primarily through 2 channels. So through our own U.S. direct sales team and through our commercial partner, TELA Bio who are responsible for sales in hernia and breast reconstruction. The technology is well established. We've treated over 6 million patient treatments with this technology, and is a large body of both preclinical, clinical and scientific evidence that sits behind this with over 83 peer reviewed publications. We have multiple approvals in the U.S. for these products. And across the globe now, we have regulatory approvals in over 50 countries. We also have a second technology platform that we're working on, this is our Enivo tissue apposition platform. I'll talk briefly about that at the end of the presentation. We're a company of 270 or so people. A lot of those people based in Auckland and then a team of 80 or so in the U.S., which is our commercial organization. The technology -- our primary technology is AROA ECM technology platform. This is a layer of tissue that we isolate from the forestomach of sheep. We purify that in a way where we remove all of the antigenic components or the components that the human body would react against but conserve the scaffold within this tissue and important secondary molecules, which are important signals for healing that are adhered to that scaffold. This tissue is an ideal source of regenerative product with a very high concentration of these signaling factors, a very ideal [ core ] structure and very complex biology that's known to improve healing in a range of different indications. From that technology platform, we've developed a range of different products. Endoform products, used in diabetic and venous ulcers, typically used several times a week. Our Myriad product or the soft tissue reconstruction, focused predominantly on trauma and lower Extremity. Our Symphony product, which is a combination of AROA ECM material and hyaluronic acid, and OviTex a combination of our AROA ECM product and synthetic polymers used to reinforce that product to provide greater load-bearing capacity in [ breast ] reconstruction. We're targeting an opportunity in excess of $3 billion. On the Aroa side, this is in complex wounds so diabetes ulcers, venous ulcers, pressure ulcers, chronic wounds and then also acute reconstruction so trauma, tumor removal, some procedures -- some general surgery and some of the inflammatory skin diseases. On the TELA side, OviTex is designed hernia repair and breast surgery. So what have we learned about Myriad to date? And if you look at the clinical need and the clinical outcomes, that surgeons are looking for in soft tissue reconstruction. Myriad suits those wounds where you want rapid volumetric fills. You want to be -- you want that wound to heal rapidly on the base. Also a very useful technology when you want to protect and cover vital structures. So things like nerves, blood vessels and bone, particularly difficult areas to regenerate tissue over. And then the third area is that where we have contamination and inflammation within wounds. And Myriad's rapid persistence and is not degraded quickly, and therefore, provides a long-acting scaffold for these sorts of situations. So Myriad really stands out in these three areas, and there's a number of seasons within these needs are particularly important. I want to talk briefly about volumetric fills. So what we see with Myriad is that rapidly fills large defects with new functional tissue. This is a series of publications that -- from studies that we've conducted over the last 2 or 3 years, these are studies of relatively large defects. And what we see here is that these wounds fill rapidly. So within 3 to 4 weeks, these wounds fill and then surgeons are able to either move to a closing procedure like a [indiscernible] graft or continue treating with Myriad and Endoform and allow them to move to closure. So these wounds fill quickly compared to alternative technologies. It's also very useful for covering and protecting vital structures. So again, a series of studies. And here, you see that we're using this technology in combination with tendon, bone, exposed viscera and [ vasculature ] and joint [indiscernible] and Myriad allows these structures to be covered and then to regenerate tissue over the surplus of these structures. And again, happening within a relatively short period of time. And then thirdly, we see that Myriad persists very well even in wounds that are contaminated and inflamed. So in these studies, you can see that these wounds are contaminated. So if you look at the CDC contamination score, you can see these are grade II, III and IV so they have a high level of contamination. So we see that in these wounds, the wounds heal, but importantly, they don't become infected. And that's an emerging finding that we're seeing with Myriad in that, it doesn't tend to become infected and lead to serious complications. So how does Myriad compare with alternative technologies? And when you look across the publications for Myriad, what you tend to see is very low rates of infection. So if you look at the top line here, Myriad being an extracellular matrix, we have very low rates of infection. So within the 11 studies that we had published, we've only seen one patient that reported an infection that's one patient out of 159 patients tracked through these studies. If you compare that to other technologies. So technologies like synthetic polyurethane foam and here, what we see is within 41 publications -- in those publications, 44% of the -- 44% of those publications reported infection or 45 of 292 patients had infections that 15% of those patients being infected. And then if you go to products like the synthetic chemical cross-linked collagen products. Here, again, you see higher rates of infection. So 90 patients out of 1,500 patients being infected so [indiscernible]. So what's important here is that when patients become infected, that requires them to go back to the operating room often or to receive ongoing treatment and also delays healing. So we're seeing with Myriad is that we don't tend to have the same complication rates and it doesn't need -- it doesn't require additional expenditure or further procedures for the patient as well. So it's helpful for the patient, obviously, and helpful for hospitals too. So what does Myriad do? It simplifies surgical soft tissue reconstruction. It allows complete tissue coverage within 4 weeks typically. Now sometimes there may be a need for further applications but on average, we see that single application can allow wounds to be closed within 4 weeks, and we have fewer complications and that's low rates of infection, and we don't see graft loss as is commonly seen with some of the other products. So I want briefly move on to our half year results. So total revenue for the first half of the year was $39 million. Product gross margin, 87%. A normalized EBITDA loss of $1.5 million, and we ended the half with $21 million -- $22 million cash balance. So very much in line with our guidance. And I think the first half of the year has generally tracked very well for us. We're breaking it down by the key products. So Myriad, it's our top priority in terms of our sales efforts where we continue to have strong momentum with Myriad, it was up 45% versus the same half last year. But clinical data continues to be compelling. So we're very encouraged with Myriad sales, and we see that continuing to grow strongly. Importantly, when you look at the Myriad sales, we still have a very tiny share of the total addressable market here. So we think Myriad has a long way to run. And I think we are increasingly confident about Myriad's ability to become a leading product within this category. The TELA Bio, again, growth on the same half last year, up 19% on H1 last year. This continues to be an important partnership for us. The hernia franchise is simply performing very well, and we're seeing some potential good tailwinds, all those products for TELA Bio. And again, we only have a relatively small portion of the total addressable market. So a lot of growth ahead of OviTex for the future. We have had issues, the previous year with inventory with TELA Bio slowing down sales. We see the situation here has now recovered as we talked about at the beginning of the year. So if you look at the gray line here that TELA Bio's sales, if you look at the orange line at the bottom, you can now see that in FY '24 and in the first half of this year, Aroa sales are tracking in line with TELA Bio sales. So we don't expect that to change now. The dotted gray line shows that TELA Bio's inventory levels have decreased but now beginning to stabilize at about 20% of -- 20% compared to total sales. So that situation where our sale -- our lower sales from TELA Bio sales were out phase, we think that's behind us, and we sort of now see these two lines tracking together. So we are reaffirming our guidance for the full year. So we expect that to be between $80 million to $87 million in terms of total revenue and with a normalized EBITDA of $2 to $6 million. So if you just break that down in 2 halves, so $37 million in the first half, 86% gross margin, a $2 million loss. As you move forward into the second half, $43 million to $50 million, continue to have 86% gross margin and normalized EBITDA of $4 million to $8 million. Importantly, in the second half, we will be positive on an operating cash flow basis. So we're making that transition to being not just profitable for the full year, but to have a positive operating cash flow. Just in terms of catalysts and milestones going forward. So continued momentum with Myriad in terms of our sales. We've had some really nice clinical data coming out over the next half that we think is going to really help us, particularly in lower limb so potential catalysts there. Our trauma and limb salvage evidence continues to be very strong. And also TELA Bio sales momentum. TELA Bio recently closed a $42 million capital raise. So they are well placed now to continue to grow sales. On Symphony, we are completing an RCT, something that will allow us to put reimbursement in place for Symphony within the next 6 to 12 months. And Enivo, we're still pursuing a clearance for that. We have several pathways that we're looking at in terms of commercializing that product. We're currently in discussions with the FDA to define any local plan for approval for that product. I'm just going to pause there. I will take questions relating to full year results now and then move on to Dr. LaLama's presentation.

Thank you, Brian. We will now move on to the Q&A session [Operator Instructions] And we have a question from Elyse Shapiro.

Looking at that MASTRR study, obviously, that's -- it's really good to see the commitment to clinical evidence in the tissue repair space. How are the sales force leveraging the data from that study? Are you starting to see increased utilization for Myriad in more types of procedures? Or is it making the process easier to get through the VAC committees and new sites?

Yes. I think the quality of the evidence is improving. So just sort of going back 2 or 3 years, we had a number of complications that were small numbers and a wide variety of procedures. And what we're now seeing is that we're having, particularly now coming from the MASTRR study and our first big publication from that will be at the beginning this calendar year. That's been accepted for publications. That's a lower limb extremity publication, 120 patients, [ 130 ] wounds. And so that just takes the level of evidence to a different level. It's a prospective study. So it's important in terms of really being able to demonstrate how Myriad's different from other products. And I think, as we -- as I mentioned earlier, it's really around that rate of healing, the lack of complications and only requiring a small number of applications. So it just gets more convincing. The nice thing is that, all of these things are self-reinforcing. So what we saw in small studies, we're beginning to see that in the much larger studies as well. So it certainly helps in terms of the surgeons that are a little bit more conservative, providing more evidence. And I think that's useful to get trials and their evaluations up and running, also useful for VAC committees. I think the other thing it's really helping us with is it's allowing us to really understand how we can bring value to hospitals. And so if we can show them that the rates of complication are low, that are not incurring extra expense for treating infections, for taking patients back to surgery that has huge implications for their costs. So I just think the whole story gets a lot more solid and a lot more convincing.

Got it. And just the detail on the run rate. The sales run rate was really helpful kind of on a rep basis. Is the aim for -- within 18 to 24 months, is the aim for each rep to be up to that $1 million in sales still?

There will be the aim. Yes, it probably on a 3-year -- yes, 3-year cycle to get up to that level. It's certainly improving. We're seeing that time between hire and ramp improve. Still probably, at the moment, I think it's probably 3 years to that [indiscernible].

Okay. We'll move on now to some written questions. We have a question here from [ Chris Webb. ] With the New Zealand sheep flock having reduced by large numbers in recent years. Is there a concern regarding obtaining sufficient raw material?

It's a question we get asked quite a lot and it's certainly been a question that we've been asked with various partnerships that we've been involved in. The answer is we use a very, very tiny amount of tissue versus the total amount of tissue that could be available. So currently, we're supplied by one small [indiscernible] it really is a tiny fraction of the total available source of tissue.

Okay. Thank you. And we've also got a question here about the cost of synthetic alternatives compared to Aroa's products.

Yes. So there's a number of types of synthetic products. And so there's synthetic polymers like polypropylene that are permanent, particularly in hernia, we see those products. They're very inexpensive, but recently being withdrawn from the U.S. market due to complications. What you're now seeing really is synthetic [indiscernible] polymers in the market. And we see those both in the soft tissue area, hernia and breast. We typically are at a similar price point to those synthetic polymers. There are synthetic biologic materials as well. So these are products where they take natural materials, they break them down and they recombine them synthetically into products. So an example of that would be [ Integra ]. We tend to be significantly less expensive than products like that. But also there's a lot of other advantages of [ our ] technology over that older synthetic biological material. So I think the short answer is we're very comparable in cost to synthetic products, which means we're incredibly competitive. I think that's something probably new that we've brought to this market. Typically, biologics have been extremely expensive, with our AROA ECM platform, we're able to make these products a lot more affordable.

And we have a question here around what the drivers are that take the range that you've given for guidance in terms of the top and the bottom?

Yes, it's a good question. I mean, really, the key drivers are Myriad and OviTex. We've obviously got -- TELA has obviously provided guidance or reconfirmed their guidance for the full year, a big uplift expected there and look -- we -- looking forward to seeing that come through. And then, of course, Myriad, I mean, Myriad is, again, there's potential upside on Myriad.

There's also a question here around whether you're able to provide any clarity around the parallel initiatives in play to progress commercialization of Enivo.

Yes. So we have with 2 of the 3 components for Enivo cleared by the FDA. So there is potential for us to commercialize it with those 2 components. And so we're looking at options around that. We -- in order to commercialize the [ full ] product, which we know [indiscernible] functionally the basic product, we need to get the sleeve cleared enough. To get the sleeve cleared in combination with the rest of the product, it's probably 12 to 24 months and that's involved with clinical study. So we're looking at how long it will take us to maybe -- what procedures could we use the catheter and pump alone while we also pursue [indiscernible] clearance for the sleeve. So a couple of options that we're looking at. I think we're working our way through that. And we're very -- I think we would like to go realize some value from this platform earlier. We think there's some other ways that we can do that.

And any thoughts on changes in health care legislation post-U.S.A. election?

I think it's too early to say. I mean I think there's a range of things could happen. I mean we're just sort of focused on what's in front of us at the moment. And -- but I think everyone -- with any changes everyone is likely to be impacted.

Okay. I think that wraps up for questions. So thank you for that, and thank you, everybody, for the questions. We'll now move on to the clinical presentation. I'll hand over now to Aroa's Medical Science Liaison, Dr. Brandon Bosque, who will provide some context and introduce our speaker, Dr. Anthony LaLama. Just a reminder also that the following slides contain sensitive medical images and your discretion is advised.

Thank you so much, Sarah, and hello, everyone. My name is Dr. Brandon Bosque. I'm a board-certified foot and ankle surgeon and certified wound specialist position based in the United States, and I serve as the Senior Medical Science Liaison at Aroa Biosurgery, where I help spearhead clinical research to grow the ever robust body of evidence around the AROA ECM. As Brian mentioned before, especially the lower extremity world can be very challenging in terms of the defect and the patient cohort affected. One study that was alluded by Brian was a retrospective study looking at 50 defects of the soft tissue across 7 sites. And again, these patients are very, very complicated, and the wounds are very complicated. This was a retrospective study and we defined patient complexity by having one or more medical conditions or comorbidities that negatively impact the wound healing such as diabetes, peripheral arterial disease, anticoagulation therapy and cancer. Now this study looking at 50 defects, utilizing the Myriad product and the inpatient surgical reconstruction, 90% of those patients had 2 or more of those comorbidities and the defects themselves had a range of about 84.2 square centimeters, which is quite large in the lower extremity. And 2/3 of those patients had exposed bone and exposed tendon and over [ half ] of those patients had a known bone infection. So these are very contaminated wounds and patients that have higher propensity to actually lose their limb because of the complexity of their defect. Now what we found is the results of this study were quite remarkable, seeing that these defects filled in with granulation tissue, covering the exposed bone and tendon and covering the depth and volume of the defect within 26 days of application. They would then go on to heal and fully epithelialize and cover with skin if not utilizing a skin graft, which is common in this cohort because patients tend to be too sick to undergo multiple procedures for a staged reconstruction. These patients healed at about 13 weeks after their Myriad application. Two other endpoints that were very important are smaller numbers. As Brian alluded to before, 1 median application, so that reduces the trips to the operating room and reduces the financial burden to the patient and the financial -- and the hospital as well. And also another really important small number, 0 complications, no infections, no seromas, no hematomas and no major amputations in this cohort. This served as a precursor to a subset of the MASTRR study, a prospective registry study looking at, as Brian said before, 130 defects prospectively managed with Myriad in the inpatient and surgical setting. Those data have been peer reviewed and submitted to a journal and hoping for publication in December. So we'll go to those results with you at a later time. That being said, while the data is a bedrock of Aroa Biosurgery and the AROA ECM, it's always great to hear from the end users, the surgeons that are treating these complicated defects and managing these very, very challenging patients. And joining us today, we are very honored to have Dr. Anthony LaLama. He is based in the Michigan area in the Midwest United States. He's a board-certified foot and ankle surgeon as well. And he specializes in reconstructive surgery, diabetic limb salvage, sports medicine and outpatient wound care. Dr. LaLama is the Director of the Amputation Prevention Center and the Residency Program Director at Providence Hospital in Southfield, Michigan, a Detroit suburb. He has authored multiple scientific publications and he's a well-regarded thought leader in lower extremity reconstruction and regenerative medicine. So with that being said, please, Dr. LaLama, we'd love to hear about your journey with Myriad as well as the new outpatient product to Symphony.

Well, thank you, Brandon. It's truly an honor to be amongst so many distinguished members here today. So I'd like to thank everybody for the opportunity to give my experience with Myriad Morcells and the Myriad Matrix as well as the most recent Symphony graft that I've been using in the clinic. Just kind of to start, the best thing that I have seen in my hands, and I've used multiple skin substitutes. I think that Myriad, the way that it is processed, what we're dealing with and what I'm dealing with mostly is chronic wounds that are stuck in this inflammatory phase of healing. And we're just trying to get them out into the proliferative phase to kind of expedite the healing process. And I think the way that this Myriad matrix and the Morcells are processed with no residual proinflammatory response has really accelerated my patients' healing rate. I'm starting to get patients that have 20-, 30-year-old wounds that have had multiple procedures done by other physicians and they can't get anywhere. So using the Myriad Matrix and Morcells, I'm really seeing the results. My patients are happy. I'm sure everybody is pretty familiar with the new LCD guidelines. I think having Myriad in my holster as well as Symphony less applications. I'm not concerned whether or not they keep it at a limitation of 4 or 8. To me, it doesn't matter, again, using this type of skin substitute, ECM, really help develop rapid healing response for my patients. And I'd say about 95% of those are one application. So with that being said, we'll get into some cases. Brandon, you can go to the next slide. So for example, this is a patient who is a 47-year-old male. I'm from Detroit, so it's a motor city. So this patient is on its feet quite a bit. He works at one of the automotive plants, has a significant history of venous insufficiency and hypertension. He had a full thickness, painful venous leg ulcer to the right lateral leg. Saw multiple other physicians, went to multiple wound care clinics. You could use any graft on any wound. If you're not addressing the underlying issue, that's a big problem. This patient, in particular, had an issue with chronic DVT, I sent him out for consultation. He had mechanical thrombectomy. And you can see he failed prior treatments with amniotic grafts, other skin subs, compression, multiple [ debridements ]. So you see his approximate size is pretty significant. He did have his venous thrombectomy performed. At that time, I decided to get aggressive. We'll take him to the operating room, and this is him on the operating table with the initial assessment and go from there. So I did a sharp debridement. I applied the Myriad Morcells. I did 500 milligrams to fill in the deficit, followed by a 10 x 10, 3-layer Myriad Matrix, rehydrated with saline. A nonadherent dressing was then applied with Unna boot compression, which is the gold standard for the venous leg ulcers. Next. So this was seen at week 4. Now something that I like to stress when I do lectures regarding this product. What you see in the middle of that wound is, I'd like to call it caramelization. So essentially, that graft is still trying to incorporate into the wound bed itself. But you're starting to get the centralized granulation tissue, this little epithelial buds right in the central aspect. At this point at week 4, I tend to be very patient. I don't debride it at this point. A lot of people would be tempted with the caramelization left on top of the wound bed. I just think that, that's the graft that's starting to incorporate even more. This patient had no complications at this point. His pain has reduced significantly. So we just continued with the compression at this point. Next. So this is him at week 5. So we have a lot of continued epithelialization centrally. Typically, we like to see epithelization come from the sides of the wound, but this is coming central, kind of growing up right in the middle of the wound. This is doing really well healthy issue, edema is well controlled. We're continuing to just let his body start to work. Now that the inflammation is gone and he's in the obvious proliferation phase. So we can go to the next slide. And here he is at week 7. So we're talking about a 2-year-old wound. And in 7 weeks, you had about 80% epithelization. So 80% new skin growth, significant decrease in drainage, no complications. You can see on the right side of the picture, which is the distal side, that part is very granular. I did start to debride in the office at this point just to kind of stimulate some more healing response next. Next. At week 8, he's about 87-- 85% epithelialized, again, no complications. And the biggest thing for some people to understand, including myself, 1 out of 3 of these venous ulcers will reulcerate. And when you see the epithelial tissue in the center aspect of this picture, it's very robust. It's not friable. At this point, I'm not really concerned about reulceration because his underlying venous disease is resolved and being treated, but also that robust epithelial tissue is not a nidus for any type of friction or reulceration at this point. Next. This is him at week 10, 90% closed, minimal drainage, no complications. We can go to the next slide. Here is at week 11, continued epithelialization. There's always 1 spot that takes longest, but he's continuing to progress. Again, no pain. He's working. He's just wearing his compression. Go to the next slide. And here he is at week 16. So very pliable tissue, good pigmentation, no drainage, no complications. This was 1 application Myriad Matrix with 500 milligrams of Myriad Morcells. He's doing really well. I see him once every 3 months, just to maintain regular care, but he is doing very well, robust skin. It's been about 2 years almost that he had this done and he still has not reulcerated, so he's pretty much in the clip. Next slide. You can see the progress. So again, a 2-year-old wound, we're going from week 0 to about 4 months, pretty significant. And the best part of this is every week I was seeing, we were seeing some progress. That's why it's -- wound care specialty in itself is very rewarding when you start seeing the progress. Next slide. So here's another case that I had. This patient was a 40-year-old male, uncontrolled diabetes, peripheral vascular disease, prior history of amputation. He had a full-thickness ulcer to the right lateral foot. He had exposed tendon. Basically, he ended up in the hospital with an abscess and his foot was turned inward on his ankle joint. And when we made the incision, one of the bones just basically was so loose and infected, it kind of popped out of the surgical site itself. So at this point, he didn't really have any stability at the ankle joint at all. So I had to take him back in with the history of chronic osteomyelitis as you could see, 9 years. Chronic osteomyelitis is very difficult to get a wound to heal over just due to the chronic bone infection. Sometimes it can become dormant. But most of the time, this requires bone resection or loss of limb. So you could see the approximate size, 4 centimeters x 2 centimeters x 0.3. Again 5 months prior talectomy was performed. That was the bone edges kind of came out of his incision site. So I needed to provide some stability to him. If I were to just graft him with the Matrix or the Morcells, he would still have the movement with the foot turning inward on the ankle joint, and he needed a solid construct of that foot to the ankle joint itself. So we could go to the next slide. So you could see, I put on this -- we call this a delta-frame external fixator. We're able to stabilize the ankle joint put the foot in a neutral position. I packed the depth of the wound with 500 milligrams of Myriad Morcells, I did a 10 x 10, layer -- 5-layer Myriad Matrix stapled it into fixation. This way, I wouldn't -- there was no sliding around of the graft that we were losing. We did a contact layer with antibacterial foam and gauze wrap. Next. This was him at week 3. So again, you see that the yellowish color, that's the grafter still incorporating. I think it's very important when using Myriad Matrix and the Morcells to be very patient with the healing process. The budding of the granulation tissue is starting to -- the graft is integrating really well into the wound bed itself. The depth has essentially gone at week 3. And he still has the stable construct with the external fixing. Next? So here is at week 10. Again, 9 years of a wound with chronic osteomyelitis, and we're 2.5 months in, where he's showing significant neodermis, good epithelialization. Revascularization of that wound bed with that nice beefy granulation tissue. No complications currently at this point. We're just letting this close in with secondary intention. Continue, next. So this is him at week 14. He did have a snag with the external fixator, one of the bolts got loose. So I had to take them in and exchange out one of the wires and the bolts. I figured while I was in there due to his history of chronic osteomyelitis, I would add another Myriad Matrix. So the wound just to make sure that we were still getting the epithelization we wanted. Next slide. And he went on to heal 2 weeks after that at week 16. Again, you could see the progress from where he was initially at week 0, moving through to 14 and then week 16 complete epithelization. He's doing -- he also has a wound on his left foot that he's had for 10 years now. And I've been using Myriad on that. He's doing very, very well. It's not completely closed yet. So those slides will give in the slide deck. So next one. So this was my Symphony patient. This was the very first time I used Symphony in this patient at Wagner Grade 2 ulceration. This is how she presented initially, a 56-year-old female has a history of Charcot neuroarthropathy, hypertension, uncontrolled diabetes. If you look at the wound bed, that tissue base is very soft. It looks like it would be firm, but it's not. It's very soft. She has no new granulation formation coming in. And these heal ulcers are very, very difficult to heal just because of the pressure that she has. So you see the measurement. It was a 3 x 3 initially. Next slide, 6 months of conservative care. So we did a sharp debridement in the office. We did the application of the 5 x 5, hydrated with saline, trimmed it to size. I've noticed that you keep it on the periphery of the wound. It will actually trap some of the moisture, so it's best to trim it down to size. We dressed it with gentian violet, which is just a drying agent and an antifungal, methylene blue foam and then we did some heel offloaded. So that was the application. Next slide. So day 4, she came in for evaluation. And you can see that the Symphony was well-adhered and integrating and significantly smaller in size after just 4 days of the application. Next slide. I'm sorry, that first slide should have been week 2. This is week 4. Week 4, you could see again notable reduction in the area from 3 x 3 to 1 x 1 after 4 weeks. Symphony integrated completely at this time. We're just kind of watching it. Next slide. Further reduction in area noted, 0.8x0.5. We continue with sharp debridement and offloading. Next slide. And then here she is by 0.2 x 0.2. So point being, this was done with 1 application. It's stimulating the patient's own cells to activate to get them out of the inflammatory phase to the phase of healing. Next slide. She went on at week 6 to be 0.1 x 0.1 in total area. Next slide. And then came out epithelialized by week 7. I unfortunately couldn't get a picture of that one. I was out of town, my partner saw her, but it still remains epithelialized after 5 months. She's able to ambulate with an offloading shoe, no complications. And again, 1 application of the Symphony down in the office setting. We just started using it in the wound care center and getting good results with that too. Next slide. So this is the initial defect and the progress that we had throughout the process. And again, I'd like to remain patient for at least that first week or 2. At week 3, I'll start to debride just to kind of get the body to react and start growing even further epithelial tissue. Next. Yes. So yes. So basically, when I'm using this Myriad, we get the volumetric fill with the Morcells anytime that there's a defect in a wound with depth to it, it rapidly fills these large defects, gets into any undermining tissue. And then it protects with the Myriad matrix on top. Again, I think with that lack of proinflammatory response, we're getting a much faster, less expensive heal rate to the patients and then the persistence keeping it out of the inflammatory phase and getting it into [indiscernible]. Next. Thank you, everybody, for your time. I'm available for any questions.

I'll just wait a few more moments to see if any questions come through. We haven't got any at this stage. Right. Okay. We have one here from Elyse Shapiro. What products did Myriad and Symphony displace, so what we were using prior, I guess?

Yes. So prior, it's hard to get -- in the operating room it was difficult to get certain skin substitutes that would cover big sizes. It took place of what I used to use was, I would say, ACell. It has taken place the Symphony with my in-office for some organogenesis products that I used to use in office, but those 2 are mainly.

Another further question from Elyse. To your knowledge, among the physician community, is there a high degree of awareness of the Aroa products?

In our community, there is, most of Southeast Michigan is on board with the Aroa products, specifically my hospital system. But yes, there's definitely -- when you look at cost of this graft compared to others, the hospital is more in tune to use that. So that's been able to get Aroa on the market at several hospitals that are in the area.

Okay. I think that concludes the questions for today. So I'll just hand over to Brian now to conclude.

Thanks Sarah. Firstly, thank you to Dr. LaLama for making time to do the presentation. Super helpful. And very nice to see the effect that we're having in some of these really, really difficult to heal wounds. The release is out today. So there's more detail in there. And we look back over the first half of the year, certainly a strong start to the New Year, and we see that momentum continuing into the second year. And certainly, we're in good shape, I think, to deliver on our guidance. So thanks, everybody, for joining, and I look forward to catching up with you next quarterly. Thank you.