Axogen, Inc. (AXGN) Earnings Call Transcript & Summary

Welcome to the AxoGen Fourth Quarter 2022 Conference Call. [Operator Instructions] As a reminder, this conference is being recorded. I would now like to turn the conference over to your host, Ed Joyce, AxoGen's Director of Investor Relations. Please begin, Mr. Joyce.

Thank you, Rob, and good morning, everyone. Joining me on today's call is Karen Zaderej, AxoGen's Chairman, Chief Executive Officer and President; and Pete Mariani, Executive Vice President and Chief Financial Officer. Karen will discuss the quarter and our outlook for the year, and Pete will provide an analysis of our financial performance, followed by a question-and-answer session. Today's call is being broadcast live via webcast, which is available on the Investors section of the AxoGen website. Following the end of the live call, a replay will be available on the Investors section of the company's website at www.axogeninc.com. Before we get started, I'd like to remind you that during the conference call, the company will make projections and forward-looking statements regarding future events, including the 2023 financial outlook, timing of the BLA submission and growth trajectory of the company. Forward-looking statements are based on current beliefs and assumptions and are not guarantees of future performance and are subject to risks and uncertainties, including, without limitation, the risks and uncertainties reflected in the company's annual and periodic reports. Actual results or events could differ materially from those described in any forward-looking statement as a result of various factors, including, without limitation, the continued impact of COVID-19 on our business, global supply chain issues, record inflation, the impacts of the failure of Silicon Valley Bank and the recent turmoil in the banking industry, hospital staffing issues, product development, product potential, expected clinical enrollment timing and outcomes, regulatory process and approvals, APC renovation timing and expense, financial performance, sales growth, surgeon and product adoption, market awareness of our products, data validation, our visibility at and sponsorship of conferences and educational events, global business disruption caused by Russia's invasion of Ukraine and related sanctions, as well as those risk factors described under Part 1, Item 1A., "Risk Factors," of our Annual Report on Form 10-K for the most recently ended fiscal year. Forward-looking statements are not a guarantee of future performance, and actual results may differ materially from those projected. The forward-looking statements are representative only as of the date they are made and except as required by applicable law, we assume no responsibility to publicly update or revise any forward-looking statements. In addition, for a reconciliation of the non-GAAP measures, revenue as reported to revenue, excluding the impact of Avive as well as adjusted core and active account numbers, excluding the impact of Avive purchases, please reference today's earnings release and materials on the Investors section of the company's website. And with that, I'd like to turn the call over to Karen. Karen?

Thanks, Ed, and thank you, everyone, for joining us this morning. I'll share the call today with an overview of our fourth quarter and our full year achievements and review our outlook for 2023. Pete will then provide more detail on our financial performance before we open the line for questions. 2022 was a solid year of key accomplishments and milestones. We delivered high teens revenue growth during the back half of 2022 and drove improved operating efficiencies across the business. In May, we announced our pivotal Recon study successfully achieved its primary endpoint as well as important secondary endpoints. Late in the year, we also saw the publication of an independent landmark meta-analysis of peripheral nerve repair. This publication provides the strongest clinical evidence to date of the performance of Avance Nerve Graft across all gap links and nerve types compared to autografts and conduits. Additionally, construction of our new processing facility in Dayton, Ohio was completed, and the validation and transition is in process. This new facility will support our BLA for Avance Nerve Graft and provide for our long-term processing capacity. We remain on track for submission of our BLA for Avance by the end of 2023 and anticipate our approval in 2024. A BLA approval will complete the regulatory transition of Avance Nerve Graft from a 361 tissue-based product to a 351 biological product. And importantly, Avance will then be designated as reference product, which would, in turn, provide 12 years of data exclusivity with regard to potential biosimilars. With over 75,000 Avance Nerve Grafts implanted since launch, we are well positioned to continue to lead and innovate in this large and developing peripheral nerve repair market. I'm proud of our team and I look forward to continuing our mission of revolutionizing the science of nerve repair. Now turning to fourth quarter performance. Revenue increased 17% to $36.2 million compared to last year. Excluding the impact of revenue from Avive Soft Tissue Membrane in the fourth quarter of 2021. For the full year, we achieved revenue of $138.6 million, a 12% increase over the last year, excluding Avive revenue in 2021. As I noted earlier, we were pleased to see our sequential quarterly improvement with high-teens growth in the second half of 2022 versus single digits in the first half. This improvement reflects improved hospital staffing and surgical capacity in the second half of the year as well as our ability to execute on our strategy and gain surgeon adoption. Giving more surgeon adopters in our core and active accounts is a key driver of our growth. As a reminder, active accounts were those that awarded at least 6x in the last 12 months and may still be in the early stages of adoption. Core accounts represent more penetrated accounts, defined as those that have had greater than $100,000 in revenue in the trailing 12 months. The number of our core accounts increased to 332 in the quarter, representing growth of 1% sequentially and 18% over a prior year adjusted level of 282, excluding the impact of Avive purchases in 2021. This represents the impact of our growth strategy to drive deeper penetration into our core and active accounts. Core accounts represent about 60% of our revenue and typically contain at least 1 surgeon who's adopted the AxoGen nerve repair algorithm for a significant portion of his or her nerve injury patients. Leveraging this surgeon's success with our products, we focus on gaining more cases with that first surgeon and gaining use by additional surgeons, including middle adopters in that account. Again, we believe our best opportunity for growth is driving deeper penetration in core accounts across all of our nerve repair applications, including trauma, breast, OMS and the surgical treatment of pain. The number of our active accounts increased to 968 in the quarter, representing growth of 2% sequentially and 3% over an adjusted prior year level of 941. Active accounts represent about 85% of our total revenue, with the top 10% contributing about 35% of revenue. We ended the year with 115 direct sales representatives, up from 111 at the end of the third quarter. We believe our revenue growth can be primarily supported by increases in our sales rep productivity, and we will modestly add additional sales reps as their territories approach targeted levels. Our direct sales force is also supplemented by independent sales agencies that represent approximately 10% of our total revenue. We strive to build market awareness of nerve repair with health care providers through our direct-to-patient initiatives, particularly for breast and pain applications. We utilize our marketing initiatives to drive patient engagement to our Resensation and Rethink Pain websites. These sites are aimed at increasing patient awareness and education of the potential for nerve repair procedures to improve outcomes for those undergoing mastectomy and reconstruction and also for those suffering from chronic neuropathic pain. Our surgeon education programs remain a top priority for AxoGen and continue to generate interest in the surgical community. Once again, in 2022, we achieved our annual goal of training more than 75% of the most recent class of hand and microsurgery fellows. We have high engagement from the fellowship training institutions, and we're well on our way towards achieving the target with the 2023 class. We remain committed to developing the clinical evidence to demonstrate the safety, performance and utility of our nerve repair solutions to support surgeon adoption of the AxoGen algorithm across our full portfolio of nerve repair products. We added 8 new peer-reviewed publications this quarter, now with a total of 215 across extremity trauma, breast, OMS and pain. We believe that this portfolio of high-quality clinical evidence is the most comprehensive in the area of peripheral nerve repair and a key part of gaining surgeon adoption. Late in Q4, we saw the publication of the most comprehensive peer-reviewed analysis on peripheral nerve repair outcomes entitled a systematic review and meta-analysis of nerve gap repair. The office compared the meaningful recovery rates between allograft, autograft and conduit across 35 high-quality peer-reviewed studies. The studies were screened for nerve injury type and similar outcome measurements, culminating with an evaluation of over 1,500 nerve repairs included in this analysis. The authors concluded that meaningful recovery rates for allograft and autograft repairs were comparable across all gap links up to 70 millimeters and that there were no statistical differences between allograft and autograft outcomes in both sensory and motor nerve repairs. Additionally, allograft and autograft repairs delivered significantly better rates of meaningful recovery in short gaps up to 30 millimeters as compared to conduit repairs. Lastly, an additional part of this meta-analysis was an examination of the acute procedure-related costs comparing autograft procedures to allograft. And the study found the costs were comparable in both the inpatient and outpatient setting. I would also like to highlight a couple of recent publications in the Oral Maxillofacial segment. One study found that despite potential concerns the cancer treatment could negatively impact nerve regeneration, the oral cancer patients in the study with allograft nerve repair reported meaningful sensory recovery rate similar to those previously published for benign reconstruction. In addition to that study, another recent publication highlighted the cost effectiveness of allograft nerve repair compared to non-surgical therapy. Patients with persistent trigeminal neuropathy or nerve damage affecting sensation in their face, tongue or jaw are commonly afflicted with high rates of depression, loss of work and decreased quality of life. This patient compared the total cost of ongoing non-surgical therapies compared to surgical repair with allograft reconstruction and found that nerve reconstruction was more effective and had lower long-term costs and represents a significant improvement to the patient. For our AxoGen sponsored research programs, we are pleased to see our RECON study discussed in the most recent annual combined hand, nerve and microsurgery meeting. Our RANGER and MATCH registries continue to enroll. And this data is an important part in informing surgeons in their clinical decision-making. Lastly, we anticipate top line data readout from our REPOSE Axoguard Nerve Cap study in the fourth quarter of this year. Continuous innovation of products and applications is a key strategic pillar for our long-term growth, and we are mission-driven to provide leading innovative treatments for patients with peripheral nerve injuries. Our Avance Nerve Graft has revolutionized peripheral nerve repair, and we're excited to see this technology expand into new clinical applications. I'd like to highlight one of these exciting initiatives for breast reconstruction patients. Restore of sensation as a part of breast reconstruction is an important quality of life attribute for many women. Our Resensation technique was developed to provide sensation for patients receiving an autologous flap reconstruction which represents roughly 20% of the overall breast reconstruction procedures. The remaining 80% of breast reconstruction procedures are implant-based. To support patients undergoing implant-based reconstruction, we have collaborated with pioneering surgeons to develop a procedure to provide neurotization to a subset of this patient population. We believe this new approach can be applied to an incremental 10% to 15% of breast reconstruction patients. Leading surgeons have seen promising results and we expect to train 20 breast construction surgical teams in this new procedure in 2023. I'd now like to spend a moment discussing our outlook for this year. We expect the full year 2023 revenue will be in the range of $154 million to $159 million, which represents about a 11% to 15% growth over 2022. Our growth in the second half of 2022 reflects our ability to execute in an environment of improved hospital staffing and surgical capacity. We're confident in our ability to gain adoption and being measured on the pace of continued improvements as hospitals continue to work through these challenges and return to more normalized operating schedules. Additionally, we expect 2023 gross margin will be reduced in the first half of the year with the transition to our new processing facility, and we expect gross margins will return to approximately 80% by the fourth quarter of 2023. We view AxoGen as a growth company and are confident in our ability to continue our long track record of a surgeon adoption and growth supported with patient focus in innovative products and applications, high-quality clinical data, surgeon education programs, and our commercial execution. We're pleased with our performance and accomplishments in 2022, which include high-teens growth in the second half of the year, through reporting of meaningful clinical data and our progress towards our new processing center and filing the BLA for Avance. We look forward to extending these accomplishments in 2023. By continuing to move into middle adopters, gaining surgeon conversion and bringing new innovation to peripheral nerve repair, we can further solidify our position as the leader in peripheral nerve repair and drive long-term sustainable growth. Now I'll turn the call over to Pete for a review of financial highlights. Pete?

Thank you, Karen. Before I get into the details of our financial performance, I want to comment on the recent disclosures regarding Silicon Valley Bank. We have approximately $8 million of cash with SVB, which is our sole depository bank. The majority of our cash, cash equivalents and investments, which consist of a variety of short-term and high credit treasury bonds and other liquid investments are held in custodial accounts with U.S. Bank for which SVB Asset Management is the adviser. We are opening new accounts with JPMorgan and have begun the process of moving the cash investments to those new accounts. And now turning to our results. Fourth quarter revenue was $36.2 million, a 17% increase over the fourth quarter of 2021, excluding Avive revenue in the fourth quarter of 2021. Growth was driven by increases in unit volume of 11% as well as increases in price and product mix of 4% and 3%, respectively. Gross profit in the quarter was $30 million as compared to $26 million in the fourth quarter of 2021. Gross margin was 83% compared to 83.2% in last year's fourth quarter. Total operating expense in the fourth quarter increased 13% to $35.6 million compared to $31.5 million in the prior year. The increase in total operating expenses was primarily the result of compensation costs of $4.1 million, including $2.6 million in stock compensation. Sales and marketing expense in the fourth quarter increased 12% to $19.9 million compared to $17.7 million in the prior year. The increase was primarily due to compensation costs. As a percentage of total revenue, sales and marketing expense was 66% compared to 68% in the fourth quarter of 2021. Fourth quarter research and development expense increased 8% to $6.8 million compared to $6.3 million in the prior year. Product development expenses represented approximately 56% of total R&D in the quarter compared to 73% last year and includes spending in a number of innovation programs across our portfolio, including the next-generation Avance product. Clinical expenses represented approximately 44% of total R&D in the quarter compared to 27% last year. As a percentage of total revenues, research and development expense was 19% in Q4 compared to 20% in the prior year. General and administrative expense increased 20% to $8.9 million in the fourth quarter as compared to $7.4 million in the prior year. The increase was primarily due to higher net compensation expenses, and G&A as a percent of revenue was 30% in the quarter compared to 28% in the prior year. Net loss in the quarter was $5.4 million or $0.13 per share compared to a net loss of $5.3 million or $0.13 per share in the fourth quarter of the prior year. Adjusted net loss was $1.1 million or approximately $0.03 per share in the fourth quarter compared to a loss of $3.3 million or $0.08 per share last year. Adjusted EBITDA loss in the quarter was $700,000 compared to an adjusted EBITDA loss of $2.5 million in the prior year. The balance of our cash, cash equivalents and investments on December 31, 2022, was $55 million compared to a balance of $59.4 million at the end of Q3. The net change includes capital expenditures of $5.5 million related to the construction of our new processing facility in Dayton, Ohio, partially offset by $1.1 million of positive cash flow in the quarter. As Karen mentioned, our full year revenue guidance of $154 million to $159 million represents 11% to 15% growth. Additionally, we expect gross margin will be reduced in the first half of the year with the transition of our new processing facility, we anticipate improvement in the second half of the year with gross margins of approximately 80% in the fourth quarter. Completion of our Dayton processing facility will include approximately $4 million to $5 million of remaining capital spend in the first half of the year. Additionally, we expect first quarter cash burn to be impacted by additional payments that are unique to the first quarter, including payment of our annual bonus, sales meetings and awards and insurance payments. We're confident that our balance sheet will continue to provide sufficient liquidity, supported by revenue leverage on our fixed cost infrastructure and thoughtful expense management. With a return to more normalized capital expenditures, we expect our operating cash to continue trending towards cash flow breakeven as we continue our path to profitability. At this point, I'd like to open the line for questions.

[Operator Instructions] And our first question comes from the line of Mike Sarcone with Jefferies.

So just the first one for you, Pete. A clarification on the $8 million of cash at Silicon Valley. Is that basically free and clear, and you're just working through the process of transferring that? Can you just talk a little bit more about the accessibility?

Yes, it is. And it is free and clear. We've seen -- in fact, we've seen cash receipts were received into that account even yesterday and our ability to move money out of that account is something that we can do. So we're making -- we're taking steps to continue to make those transitions.

Got it. Okay. And then just wanted to get an update. Could you parse out what you're seeing across trauma, OMF and breast RECON so far through the year? And then what's baked into your assumptions for 2023 at the low and high ends of guidance?

Yes. Well, let me start off with the guidance. I mean our top end of our guidance really takes into consideration the continued predictability and consistency of hospital staffing and surgical schedules, although we recognize that, that's not -- it's still not at capacity. And so we've seen improvement over the last half of the year. And we would expect to see just that continued stability and not a lot of improvement is in our top end of our guidance. And the bottom end of our guidance really assumes that there is some disruption to the improvements that we've seen over the back half of the year. And I'd say, as we're starting into the year, we've seen some nice stability in those procedures, but we're going to continue to be measured in our outlook for how we see the rest of the year go.

Yes. And if I look at what we've seen, hospitals are still understaffed and they're not able to run all of their operating rooms to full capacity, but it has become predictable. And so we see surgeons in breast, in OMF and in pain where the procedures are scheduled to be able to at least schedule their procedures so they understand what their cadence will be of surgery. The breast surgeons are still working off of a long backlog, and that will take a while, as we've talked about before. But they are able to work through the cases on a regular cadence. In trauma, there has been through last year and into this year some disruption in the ability to take a patient immediately from the emergency department into an OR just because of the lack of flexibility of resources. That has stabilized. They're not always able to do that, but they can refer them and get them into an OR, either at that site of care or an alternate site of care, they may delay it a day, but they are able to do that. And so that's what we mean by predictability, is that we're seeing that the surgeons and the hospitals are creating workaround so that patients can get care and that seems to be holding through the beginning of the year here.

Our next question is from the line of Chris Pasquale with Nephron.

Given the fact that mid-March I was hoping that you could provide some thoughts on first quarter. Historically, you get about 22% of full year revenue in the first quarter of the year. Do you expect a similar seasonality in '23? And any other considerations we should take into account in terms of how the year is going to come together?

Yes, I think we are returning to typical seasonality. We have these overlays in the past of COVID and hospitals being shut down and then staffing challenges. But we are seeing, again, in this pattern, while they're still constrained in OR capacity, we're seeing a return to what I think are more predictable patterns. And so we would expect our big step-up in revenue to be during the times of more activity where people unfortunately have more injuries, which is our summer months. So we'd see a step-up in second quarter, another step-up in third quarter as our bigger growth periods with things being more level in Q1 and Q2. So I don't want to give guidance for the Q1 so far, but I think our patterns are certainly more predictable.

How do you think about the revenue potential for the nerve gap product and whether you could get some incremental commercial momentum post the REPOSE results?

Yes. I think we published the pilot results from the nerve gap product, and we're quite pleased with the pilot data that we saw. And again, it's a smaller uncontrolled series. We're completing the randomized portion of that study now. But I think what we've seen is that this concept of surgically managing neuroma is something that has a significant impact to patients. And so we're working through really educating surgeons on the ability to use nerve gap in a variety of applications. And those would include things from amputations of digits, fingers, toes through some surgical procedures in the orthopedic space where you need to cut nerves to access the joint or the surgery that you're trying to get to, but sometimes those patients end up in chronic pain. And we think we have applications to all of those, and now there will be an opportunity to educate surgeons on the benefit they can provide their patients with that surgery.

Our next question comes from the line of Kyle Rose with Canaccord Genuity.

Great. Just wanted to -- as we think about guidance in 2023, how should we be thinking about the growth of the underlying new -- or active accounts and core account growth? And I guess, put in other way, how much of the growth in '23 comes from volume versus price and mix? And if you could just break out those dynamics, that would be helpful.

Yes. If you apply revenue guidance of 11% to 15%, I think we've been successful at taking price over the last several years, and we would continue to expect as we sort of low single-digit price again in 2023. We've also had some mix impact in revenue here in the fourth quarter and in some previous quarters. The way we think about the mix impact is more flattish in the coming years. So the rest of that -- based on where you put your model, the rest of that would be in units. And I think that's -- we've had 11% unit growth in this quarter and similar Q3. So, I think that's the way we kind of think about it from a unit and price perspective. What was the first part?

Core and active.

And it's more -- its driving [indiscernible] gaps in current accounts.

Active and core accounts. Yes, this is mainly about rep productivity. We continue to believe we have a lot of opportunity to drive growth through rep productivity in our accounts, these reps have been in their accounts, most of them have been in accounts for years now. And we've got good connections with surgeons, good connections with the support staff within the hospitals and their ability to continue to drive growth along with the data that we've come out with recently, I think, allows them to continue to drive their own increased productivity and do so within their core accounts. And so we could see a mix of both increase of core accounts as well as revenue per core account across 2023.

Okay. And then obviously, the ramp of the manufacturing facility and the submission and eventual regulatory decision on the BLA, those are big milestones for the company. So I'm just wondering, can you frame out any interim, I guess, things that need to happen along the way before your manufacturer is fully certified and running? And then also view similarly on the BLA filing, just making sure that investors understand all the milestones over the course of the next, call it, 2 years?

Yes. So we are initially transitioning Avance into the new manufacturing facility as a tissue product. So that's the first milestone, and that's the work that we're doing right now. So that transition will be completed here in the first half of the year. We then revalidate as a biological product and I know that sounds like double work, but we did spend a lot of time in conjunction with the FDA trying to figure out the best way to do this validation and decided a 2-stage validation just made it cleaner. So we will revalidate the facility as a biologic. Again, there's no specific process changes, but the data on how you gather data is different between the 2 validations. That's probably the biggest milestone for filing the BLA -- what is the long lead time item and the biggest milestone for filing the BLA yet this year. We do expect to get the BLA completed by the end of the year and submitted. And then it's into the FDA process. So I'm not sure that there will be milestones that we can really see until they come.

Our next question is from the line of Ryan Zimmerman with BTIG.

Just following up on Kyle's question about the BLA. I just want to understand kind of your confidence level in getting the BLA and after it's submitted, is it -- remind me, is it 180 days that they have to respond? How long just as we kind of think about '24 and where that could come in?

Yes. So confidence is we passed our primary, our endpoint in our pivotal study. So we feel pretty confident in this process. Now there's a lot of information that we are compiling and providing to the FDA, including this manufacturing facility, but we're far enough along in the manufacturing facility. I feel very comfortable that it's -- while it's a big project, it's just making sure we have all the documentation, right? The -- actually, the facility is beautiful. So we think it will be a very effective biologics processing center. In terms of the submission time, I'm going to hesitate a bit. We do technically have the RMAT designation, which gives us an accelerated review. I'm not -- I think we have to be flexible on that because I'm not sure all the timings have been as accelerated, but FDA has been catching up. So if we get that, then we should see something with a 6-month clock. If not, it may be a little longer.

Okay. That's helpful, Karen. And then couple of other quick questions for me. If I look at account growth, active account growth for the year, so about 17 accounts relative to kind of what you've done historically. How do you think about the pace of account growth -- active account growth and core account growth for that matter as we look ahead to next year? Given that it has slowed down, is it even a good proxy for us to think about -- it's a metric you guys have given out for some time now.

Yes. I think it's helpful, but our first priority is now driving deeper penetration within those accounts. The accounts we're in, we're by far and away, lightly penetrated. And so that is our lowest-hanging fruit and the way that we think that we can achieve better sales rep productivity. So we will move some active accounts into being core accounts. There'll be some growth just organically in active accounts. That threshold is actually quite low. But I think the number that you want to continue to watch also is the average revenue per account or just think about what's the penetration into those accounts.

That's helpful, Karen. And then squeeze one more in. You mentioned flap reconstruction for breast RECON. Just curious if you could kind of size the market opportunity that you're referring to. I think you said it was around 20% of those cases. And then you guys -- I know you're targeting 20 today, but -- but help us understand, I mean if -- I don't know if there's X breast RECON procedures and 20% of those are at the flap reconstruction, what is that on an annual basis, just in absolute terms?

Sure. So breast reconstruction -- so I'm going to back up a second and just explain a little bit about breast reconstruction. The breast reconstruction for women who have a mastectomy can be done by a variety of techniques, but they fall into predominantly 2 buckets. One is the flap, where they use autologous tissue to reconstruct the breast mount and the second are implant-based procedures. And so we have historically been focused only on the flap procedures. Those are about 15,000 to 20,000 procedures a year, just depending on the data, but 15,000 to 20,000 procedures -- or excuse me, patients per year. So we have really been focused in that segment. But as happens when there's a new tool available, some leading surgeons have really been looking at that other portion, the implant based repairs and saying, well, these women have numb breasts as well, and that's a problem. And is there something that we can do to assist these women? And obviously, you can't innovate the implant, but they often have a lack of sensation on the skin and the nipple areolar complex. And that's an important part of sensation. And so techniques were developed that would allow some -- a subset of some of those patients. And it really has to do with length and size of the implants and whether we can actually have the sufficient length to reach the target at the nipple and areolar complex. So that's why we're saying as we're seeing this process -- or procedure expand into implant-based procedures, we're estimating that it's going to be for a portion today. Now this is evolving as surgeons are figuring out enhanced surgical techniques to try and reach better, a broader set of patients. But right now, we would estimate that in this implant-based group that we can assist about 15% to 20% of those patients.

Our next question is from the line of Ross Osborn with Cantor Fitzgerald.

Congrats on the progress. So starting off with some of your smaller verticals. Have you seen any return of growth on OMF to start off the year with those surgeons that were using Avance before COVID to improve quality of life? And what can you do to accelerate growth in the third?

Yes. Thanks for the question. Yes, we saw all messed at -- depressed during COVID, people became concerned about having surgery in their mouth. And it was -- has just been the neurotization in OMF has been slow to recover. And we're starting to see that in the Q4 time frame, we see that the 2 publications that I mentioned will also be very helpful. One of the things -- the majority of the work that we've done in OMF has been in benign mandible reconstructions. And then some of the injuries from dental procedures, so wisdom teeth extraction and putting in dental implants. And of the 2 papers that I mentioned, this is the first case series looking at patients with malignant tumors and having a mandible reconstruction. And the concern is then well with the follow-on treatment radiation in particular, that these patients have affect the nerve regeneration and what this paper showed is that these patients actually achieved quite good meaningful recovery rates. And so we think that will be very helpful for surgeons as they're making decisions about the care pathway for these patients and they're really trying to achieve quality of life for patients in both benign and malignant tumor reconstruction. The second paper had to do with the iatrogenic injuries from dental procedures and just recognizing that these have a lifelong impact to patients when they have numbness in the lips, in the tongue, in the mouth that, that can have impact in both self-esteem as well as sort of practical things in the way that you interact and chew and shave and sort of live your life. And so that will be helpful, I think, as we reengage surgeons. So we're optimistic in what we see. Long answer is we're optimistic with what we see with OMF and expanding into head and neck with mandible reconstructions. We think that will be a nice opportunity to continue to reengage with those surgeons and bring in new surgeons who can adopt this procedure.

Okay. Great. And then would you discuss your efforts on accelerating the referral process from patients showing up on your Rethink Pain website?

I'm sorry, it's hard to hear the question. Can you say it again?

Sure. would you discuss your efforts on accelerating the referral process from patients showing up on your Rethink Pain website?

Sure. Thank you. Yes, we really have learned a lot on activating patients through the work that we've done in Resensation. So helping women in that case, be advocates for their own health care to go in and have be armed with the questions to ask their surgeon and decide if sensation in breast reconstruction is important to you. Then if it is important, then here are questions to ask your surgeon, here's what you can do to take control of your care. And we're looking to apply a lot of those same tools into helping patients who suffer from chronic pain, determine do they have potentially a neuroma that is the cause of the pain or was it neuropathic pain? And if it is, how can they find a surgeon who does a surgical treatment of pain or a pain surgeon rather than ending up in a paying clinic as their primary care, which will address the symptoms but not address the cause of the pain. And so we're seeing early success in applying those same tools. We still need to build out more information for patients. In pain, it is more complex than a -- than in the reconstruction. If you're a woman, you have a mastectomy, you know you have a mastectomy and are thinking about reconstruction. In pain, you know you have pain, but you don't know that it's a neuroma pain. And so we have added some tools to help those patients determine do they have neuroma pain and are they an appropriate potential surgical candidate, with, of course, the final decision always being made by the health care practitioner. And so we're going to continue to build out those tools this year, but we think that we can help activate these patients, again, to be good stewards of their own care.

Our next question comes from the line of Dave Turkaly with JMP Securities.

Karen, the meta-analysis that you talked about that large review, who actually did that? And where was that published?

It's published -- it's e-published in PRS. It's a group of independent authors who actually wrote it, but they did this, again, deep review of the data and prepared a very solid analysis of nerve repair across autograft, allograft and conduits. So we're very excited to see the data. And it was e-published at the end of December. It will be in print in one of the coming journals. It's actually not been out in the -- so PRS is Plastic and Reconstructive Surgery.

Great. I know people have asked a little bit about the guidance and I was looking at the sort of rep productivity. And I was wondering if you had any color or comments there in terms of kind of where your average folks are today and sort of where you think they can go? Is there still room for that to expand?

Yes. No, we're seeing that rep productivity has -- it's now over about $1.1 million per rep. And we've always said we've got reps that do $2 million a year and maybe a little bit more. And we -- as a rep is getting close to $2 million, that's when we split those territories and bring additional resources in to cover those hospitals. So we think there's plenty of opportunity for rep productivity to go from $1.1 million up to $1.3 million, $1.5 million plus on average as we continue to drive deeper into these accounts. Now that's not all this year, obviously. But over time, we're going to increase rep productivity, we think, fairly solidly. And then as we move up the curve from $1.1 million to $1.2 million to $1.3 million, we'll continue to add more reps, and we'll do so in a way that allows us to not only drive additional rep growth but continue to drive rep productivity growth. And so we think we've got a lot of opportunity with rep productivity to be the primary driver of growth. And we certainly believe we're still in the very early stages of growth even in our best core accounts to continue to bring in additional surgeons within those accounts across our applications.

And one last one maybe for Karen. The timing of the next-gen advanced product, I think you said is later this year, but I guess, would that be sort of like used across all indications or will be designed more specifically for one? Or I guess any color or thoughts on timing and what might be new about it, if you can elaborate?

So this is -- you're asking specifically about NextGen Avance?

Yes.

Yes. So we haven't given any updates on a description of the product. I can tell you it won't be available this year. We'll complete the BLA and then be talking with the FDA about the second generation and on Avance. And then we are also working on some concepts for a third-generation Avance with the idea that we would like to have a third-generation Avance 12 years from now.

At this time, we've reached the end of our question-and-answer session. I'll hand the floor back to Karen Zaderej for closing remarks.

Thank you, Rob, and I'd like to thank the AxoGen team who remain very committed to our mission of improving the quality of life for patients with peripheral nerve injuries. We're happy with the progress we've made towards our goal this year, and we remain focused on ensuring our long-term success. I want to thank everyone for joining us this morning. Thank you, and have a great day.

This will conclude today's conference. Thank you for your participation. You may now disconnect your lines at this time.