TELA Bio, Inc. ($TELA)

Good afternoon, ladies and gentlemen, and welcome to the TELA Bio Fourth Quarter and Full Year 2025 Earnings Conference Call. [Operator Instructions] As a reminder, this conference call is being recorded. I would now like to turn the conference call over to Louisa Smith from Investor Relations.

Thank you, Jonathan, and good afternoon, everyone. Earlier today, TELA Bio released financial results for the fourth quarter and full year ended December 31, 2025. A copy of the press release is available on the company's website. Joining me on today's call are Tony Koblish, Chief Executive Officer; Jeff Blizard, President; Roberto Cuca, Chief Operating Officer and Chief Financial Officer; and Jim Hagen, Senior Vice President of Strategic Operations and Marketing. Before we begin, I'd like to remind you that during this conference call, the company may make projections and forward-looking statements regarding future events. We encourage you to review the company's past and future filings with the SEC, including, without limitation, the company's annual report on Form 10-K and quarterly reports on Forms 10-Q, which identify the specific risk factors that may cause actual results or events to differ materially from those described in these forward-looking statements. These factors may include, without limitation, statements regarding product development, pipeline opportunities, sales and marketing strategies and the impact of various additional risk factors as identified in our regulatory filings. With that, I'd now like to turn the call over to Tony.

Thank you, Louisa, and good afternoon. Thank you for joining TELA Bio's Fourth Quarter and Full Year 2025 Earnings Call. For today's call, I'll open with a summary of what we accomplished in 2025 and thoughts on our forward-looking strategy. Jeff will then walk through the foundational changes we implemented in the commercial organization and how we anticipate they will impact our future performance. Roberto will review our financials, and then we will open it up for Q&A. 2025 in the third and fourth quarters, in particular, were periods of meaningful strategic change across the entire organization. Following Jeff Blizard's appointment as President, in June, we undertook and executed a significant rebuild of TELA Bio's commercial foundation while maintaining our commitment to improve our operating discipline and continuing to advance our pipeline strategies. We made meaningful changes to the U.S. commercial organization while delivering 16% full year growth and achieving record fourth quarter revenues. The ability to maintain that momentum while executing such fundamental change in the organization is a testament to the caliber of our team and the value proposition of the OviTex product portfolio. We enter 2026 with the largest, most effective field team in the company's history and the commercial strategy designed to drive durable, predictable growth. Demand for our products remain strong and the opportunity in hernia repair and plastic reconstructive surgery has not diminished. The foundational changes we undertook in 2025 were aimed at ensuring we have the commercial infrastructure to consistently and effectively capture that demand. Revenue growth in 2025 was fueled by strong performance in our European business, further adoption of our IHR, LPR and LIQUIFIX product lines and the continued contribution of our tenured reps in the U.S. The strategic investment we have made in high-caliber candidates with the right profile has been an underlying tenet of the commercial rebuild. A meaningful portion of our approximately 90-person sales force is still early in their tenure with 40% of the reps having joined TELA in the last 6 months. This has not been a function of rep turnover, but rather an investment in commercial expansion and in recruiting talent with the right profile for the sales model we are building. We already see the newest reps meaningfully outperform their predecessors in the early stages of their onboarding, and we are encouraged by their promise to execute our commercial strategy more effectively. In the fourth quarter, we accelerated efforts to bolster our U.S. commercial team by advancing recruitment to meet our sales headcount target and by putting the infrastructure in place to support those new hires. That included investing in training, rolling out new sales enablement tools, launching a new U.S. sales leadership structure and redesigning the 2026 compensation plan to align with our growth strategy and expectations. Heading into 2026, we are focused on 2 strategic growth priorities. First and most importantly, we are committed to sustaining the momentum we achieved in 2025 and achieving further U.S. and European sales growth through improved talent, processes and commercial leadership. Jeff and his team have made incredible progress so far, and this will continue to improve as the new commercial organization matures and tenured sales reps begin to hit their stride. Again, I'll let Jeff provide further detail on the specifics, but I'm confident in the new commercial foundation we have laid. And second, we have been and will remain hyper-focused on offering the best soft tissue reconstruction product portfolio in the market. Product innovation is at the core of TELA's identity, and we anticipate announcing additional product launches throughout the year to drive greater share gains in the expansive U.S. market. Demand for our innovative solutions is there, and I believe we have built a commercial infrastructure supported by an expanding portfolio that can consistently capture that demand. To that end, we were pleased to announce the promotion of Dr. Howard Langstein to Chief Medical Officer effective March 1. Howard joined TELA nearly 2 years ago and has been instrumental in how we engage the surgical community. With over 30 years in plastic and reconstructive surgery, he understands this market from the inside out, the procedures, the unmet needs and what surgeons are looking for. As TELA's CMO, he will drive surgeon awareness, support clinical education, and help generate, disseminate and translate growing body of data behind OviTex into a broader market understanding and acceptance. On the European side, our teams are stable, tenured and delivering above plan. The competitive market in Europe differs from the U.S. with pricing and the bundling dynamics, and we are encouraged to see rapid adoption of OviTex in the U.K. and the Netherlands. We are winning share based on patient preference and the efficacy of our products in these markets, not because of pricing discounts or volume requirements set by hospital administrators. Moving forward, we have a purposeful investment plan to expand our presence within Continental Europe and see it as a meaningful contributor to growth in the coming years. Overall, Q4 results reflected a commercial organization in transition, but we remain proud of all this team has and will continue to accomplish. We executed a major commercial upgrade in the back half of 2025 while simultaneously achieving several other key milestones for the company. In that 6-month period, we launched OviTex LTR, a new addition to our portfolio that offers durable support during healing and provide surgeons with a tissue-based alternative to synthetic mesh. We enrolled the first patients in our hiatal hernia trial, [ ECHO ], which will strengthen our clinical evidence space and deepen our access to alternative surgeon call points in a primarily robotically performed procedure. We reinforced and upsized our debt facility, strengthening our balance sheet for the road ahead. And finally, we upgraded our Board of Directors with new expertise. In summary, 2025 was a year of a deliberate foundational change that required discipline and conviction. That is behind us, and we entered '26 with our eyes towards the future. With that, I would now like to turn the call over to Jeff for a more in-depth review of our commercial strategy and restructuring. Jeff?

Thanks, Tony. As Tony laid out, I don't want to lose sight of the fact that a mid-transformational reorganization, we grew revenue by 16% and delivered our third straight quarter of sequential growth. We exceeded $80 million in total sales for the full year 2025, all while maintaining operating discipline and improving our operating leverage. The changes that we undertook since coming on board last June could have created significant disruption in productivity and growth in any organization. That didn't happen here. It speaks volumes to the commitment of the entire TELA team and the dedication to the patients and customers we serve. I'd like to take some time to provide a detailed review of the specific changes in our commercial organization that Tony referred to. I'll also highlight the progress we made year-to-date because of these changes and how they set us up for meaningful inflection moving forward. Number one, we upgraded and redesigned the U.S. commercial leadership team. By implementing a new sales general manager structure, we brought on decision-making closer to the customer and empowered teams to respond to customer needs in real time; two, concurrently, we addressed silos within the commercial organization that had been slowing across team collaboration. We strengthened our sales leadership bench by upgrading 5 key senior roles. These changes were implemented to increase accountability in the field, improved coordination across our hernia and PRS segments and drive more consistent execution across our commercial footprint. Three, we've rolled out formal promotion pathways within the commercial organization, creating vertical career mobility that rewards our top performers and incentivizes meaningful contribution within the organization. Four, we redesigned the sales talent profile in the U.S. and accelerated our hiring. We hit our 76th territory manager target back in the third quarter. And as of today, we have 88 quota-carrying territory managers in the U.S. with 1 additional hire imminent and 5 open positions that we're actively sourcing. This means we won't require any further incremental hiring for the remainder of the year. The team that we need to hit our 2026 targets are largely in place. Tony touched on how we evaluate our field teams by distinct cohorts and how we assess their performance by tenure and productivity ramps. Roughly 40% of the U.S. field team have joined us in the last 2 quarters. They are in the early phases of their ramp up, and we expect that they'll contribute incrementally each quarter of this year as they build out account relationships and gain clinical familiarity. An additional cohort, those who've been with us between 6 and 18 months have gained meaningful traction and the vast majority have reached a productivity inflection point. They're actively building account relationships while improving clinical acumen. We expect their contribution to ramp meaningfully each quarter. And finally, we've maintained a very solid base of tenured reps who, on average, deliver over $1 million per year and consistently meet our -- or exceed targets on a monthly, quarterly and annual basis. This cohort accounts for approximately 35% of our current rep count. Five, as part of the redefinition of our sales talent profile, we've shifted our approach to recruitment. We've been very successful not only in our ability to retain top performers, but then in our ability to attract and hire strong candidates. We increased our investment and focus on sales training, and with the goal of reducing time between hiring and commercial effectiveness. The candidates we're bringing in demonstrate stronger performance and higher scores on all evaluation criteria versus any prior cohort. The profile we're recruiting combines high intellect, perseverance, the ability to build deep and lasting relationship and develop strong clinical acumen over time. This is a change from our previous recruiting strategy, which place greater emphasis on years of soft tissue sales experience. The caliber of our newest reps is beyond anything TELA has ever seen. We're becoming a destination now for candidates to fit a clear profile for success in the commercial model that we're building. Naturally, as we place less emphasis on prior soft tissue experiences a ramp-up period while new hires come up to speed through our clinical education programs. What we're seeing, however, is that our investment in sales training, this new profile of rep gains clinical proficiency quickly. And once they do, their drive and hustle translate into a higher level of contribution than prior cohorts. While we're still expecting most new hires to reach full productivity within 6 to 9 months, we believe their impact to maturity will be greater. Six, we've developed and rolled out a new sales enablement technology that draws on better market insights to help our sales leaders and reps better prioritize and target their activity. Seven, we have designed and implemented a new 2026 compensation program that incentivizes deeper penetration in target accounts. This represents a change in our geographic coverage where we are now matching rep density with high-volume institutions to cultivate multiple users per site. Instead of a wide and shallow approach, we're going deeper to generate sustainable recurring revenue opportunities. Our new comp plan is now explicitly aligned around that strategy. Additionally, this philosophy expands beyond the comp plan itself. It also minimizes the geographical areas that reps need to cover, maximizing efficiency, and supporting better operating expense optimization. As part of this renewed approach, we're also ensuring meaningful executive presence in the field. Tony was calling on strategic accounts as recently as last week and others and I are doing the same. It's a signal in the organization to our customers, what about our priorities lie, building deeper, more meaningful physician relationships. Eight, we've adjusted our sales and marketing focus to center on the mechanism of action of OviTex and the science that fundamentally differentiates our portfolio. Surgeons have embraced our data and the long-term patient outcomes it demonstrates. The source material of OviTex and the way it integrates within the body differentiates us from any Gen-1 biologics synthetics or biosynthetics and it's foundational to the why surgeons adopt OviTex. We also increased our sales and marketing focus on LIQUIFIX. With great support from our partners at AMS, LIQUIFIX is not only a better fixation solution. We've seen it open doors with hernia surgeons who may not yet be familiar with OviTex. And finally, number nine, we've been still spending discipline within the organization, which has allowed us to fund more customer education and training events. This helps us meet customers where they are in their adoption life cycle, while simultaneously improving operating margins. So how does this all come together with respect to driving revenues. For full year 2026, with each of the 3 cohorts performing as expected, we're confident that we will grow revenue over 2025 by at least 8% and for the first quarter, to which much is already completed, we expect that we'll deliver revenue of approximately $18.5 million. The breadth of change that we executed in 6 months was significant and we recognize what it takes to sustain this level of momentum going forward. Our goal is to have everything in place by the end of Q1 so that the second half of 2026 reflects this full benefit. We are well on pace. And as of today, all significant material changes have been implemented across the entire organization. We've set our revenue guidance to account for some of the inherent variability that may arise given the scope, scale and speed of changes I've just laid out. We believe that, particularly in the second half of this year, the annualization of our commercial restructuring and the ramp of our newest cohort, combined with the pipeline and clinical investments position us to be able to deliver achievable, and sustainable results moving forward. I'll now turn the call over to Roberto for further details on the fourth quarter and full year financial results.

Thank you, Jeff. Revenue for the fourth quarter of 2025 increased 18% year-over-year to $20.9 million and grew 16% for the full year to $80.3 million with revenue from OviTex growing 12% and OviTex PRS growing 20% for the year. The growth was primarily due to the addition of new customers, growth in international sales and the U.S. launch of larger PRS units. Growth was partially offset by a mix shift in our hernia product line as we saw an increased share of smaller-sized IHR units. OviTex unit sales grew 20% for the quarter and 22% for the year while PRS unit sales grew 12% for the quarter and for the year. LIQUIFIX revenue more than tripled over the fourth quarter of 2024 reflecting early commercial traction as we expand adoption alongside our core OviTex portfolio. European sales accounted for 15% of total revenue or $12.1 million in 2025, a 17% increase from $10.3 million in 2024, reflecting the traction we are seeing in key markets and our continued investment in expanding access globally. Gross margin was 66% for the fourth quarter and 68% for the full year compared with 64% and 67% for the prior year periods, respectively. The improvement was driven by lower excess and obsolete inventory expense as a percentage of revenue. Sales and marketing expenses were $14.5 million in the fourth quarter and $63.2 million for the full year compared to $14 million and $64.6 million for the prior year periods, respectively. This was mainly due to commissions rising with stronger revenue in both periods offset by lower compensation, severance, consulting and travel costs for the year. General and administrative expenses were $3.8 million for the fourth quarter and $15.7 million for the full year compared with $3.6 million and $14.7 million for the prior year periods, respectively. R&D expenses for the fourth quarter were $2.1 million and for the full year were $9.2 million compared to $2 million and $8.8 million for the prior year period. Loss from operations was $6.6 million in the fourth quarter of 2025 and $33.8 million for the full year compared to $8.4 million and $34.1 million in the prior year period. Net loss was $9 million in the fourth quarter and $38.8 million for the full year compared to $9.2 million and $37.8 million in the prior year period. We ended 2025 with $50.8 million in cash and cash equivalents, having further strengthened our financial flexibility by refinancing our debt facility and raising incremental equity capital. As Jeff described earlier, for 2026, we anticipate revenue growth of at least 8% over 2025 with Q1 2026 revenue of approximately $18.5 million. We expect that operating loss and net loss will continue to decline for both the year and over the quarters of the year, although there is likely to be some step-up from the just past fourth quarter to the first quarter particularly in light of the revenue progression that we typically see over this period. With that, I'll hand the call back to Tony for closing remarks.

Thank you, Roberto. As we have done in prior quarters, I'd like to end with a patient story to ground us in the impact of our mission. A 57-year-old patient actively being treated for chemo required treatment for hernia repair in the intercostal region. The surgical team concerned about where the hernia was located because it was near chest tubes decided that OviTex's Core with the 4 layers being thin enough, unlike a traditional biologic would provide less seroma and was the best choice because of Core's resorption profile and its optimal size. The patient underwent an underlay procedure. The surgeon said that the patient is doing great and is extremely pleased to have OviTex Core available for this very sick patient. The surgeon commented in quotes, "We believe that OviTex is the only product that can be used in conjunction with the use of chemotherapy due to the way it rapidly incorporates its porous nature and its functional remodeling of healthy tissue. This is another great example of how OviTex can be used in the most complex of cases with excellent outcomes." Before we open the line for questions, I want to take a moment to recognize the entire TELA team. In the back half of 2025, this organization undertook a fundamental rebuild of our commercial structure while continuing to grow revenue, serve customers and maintain operating discipline to sustain momentum through the transition of this magnitude reflects the quality of the team and the strength of the products. The changes we made in 2025 were difficult but necessary. And we entered 2026 with the strongest commercial team in the company has ever had, and I look forward to what's ahead for TELA. Jonathan, please open the line for questions.

And our first question for today comes from the line of Caitlin Roberts from Canaccord Genuity.

I guess starting off with the fiscal year top line guidance for at least 8%. Just a little bit more color on why it was below what you guys noted on the Q3 call. And if you could provide some cadence to that guidance for the year, that would be great.

Yes, I'll start it off, and then I'll turn it over to Roberto. So our thought here is given the change that we've implemented -- wholesale change, right, across almost every dimension that we thought it would be prudent to set the guidance where we did. There's so many new reps and new moving parts that are in place right now, we want to give ourselves the best chance to do a great job this year. And given that our Territory Manager breakeven point remains about 6 months to 9 months, and we've hired so many new reps that we're sort of scaling into, cascading into the year, we just think there's a lot of variables, and we wanted to make sure that we're giving ourselves plenty of room to allow these reps to mature and drive. We really like the contribution from the 40% new reps so far. It looks like they've stepped up quite a bit as a percent contribution over Q4, but we want to make sure that we're giving ourselves that time and flexibility. There are some other factors that we have in place, I think, that give us confidence to do a good job this year. And that is the fact that for the first time in the company's history, we are right on the mark with the number of reps we wanted to hire and at the right time, right? In the past, we've sort of been stuck between 63 to 68 reps. I feel like that was where we were stuck. No matter where our target is, but this new commercial leadership team has done a great job of getting those folks in place. We've got a product that we think is powerful that's going to launch April 1 fully. It's been in limited release. It's our long-term resorbable OviTex product, which should give us a great match up with the leading biosynthetic out there Phasix. And I do think that's going to be mostly additive to the portfolio, along with some cannibalization from our permanent portfolio. I think one of the foundational drivers that we can rely on going forward is European performance. This has been very consistent, and I do think that they're going to allow us to allow themselves to grow consistently over time, and we very much look forward to adding PRS to their portfolio for sales, hopefully, by the end of this year or early next year. One of the big factors that we have here, Caitlin, in this guidance set is contract conversion, right? Our sales force has been very focused on getting contracts in place. And we haven't done as well as executing into those agreements. So we're going to shift that focus towards contract execution. And we do know that there's a high degree of contracting complexity, right, which does affect timing, which is another factor of safety of why we built the guidance the way we did, right? Contract implementation varies from hospital to hospital. Even if you have a GPO contract in place, we're learning that every day. And the way contracts are written in the U.S. further complicates things with a market share and a cross product portfolio bundling and rebate structure. So there is some complexity there. We want to make sure that we give ourselves the time to execute into the contract footprint that we already have in place. So hopefully, that gives you a flavor of what we're trying to do here on a bigger picture. We have a lot of factors of safety built in and a lot of potential upside, but we want to be prudent.

And let me just add 2 things, Caitlin, you asked about cadence for the year. So we do expect the cadence for the year to be similar to that in prior undisrupted years where you see a step-up from the first to the second quarter, a smaller step up from the second to the third and then a bigger step up again from the third to the fourth quarters. The step up in the second and third being smaller is driven primarily by the summer holidays. And we expect to see that pattern slightly amplified by the addition of all the sales reps that have come in over the course of the end of the fourth quarter and through the first quarter, we'll begin becoming productive in about 6 months. So we do still see that the most recent cohorts of sales reps hit breakeven just under 6 months and then what Jeff and Jim called breakout between 6 and 9 months, so become more than just breakeven positive -- profitable.

And all of these factors, Caitlin, they also add to the frustrations that everybody has had including us in the past about our forecasting accuracy, right? So we want to make sure -- again, the word is prudent, to make sure that as we're going through all of this, we feel very confident that we'll come out the other side with a much more predictable and forecastable business. But until we get there, we think it's best to be prudent.

Understood. And maybe just one more for me. I think, Tony, you touched on the contracting, how many IDNs or GPOs have you transferred to really recategorize OviTex. You talked about that the last couple of quarters. What are your expectations to continue doing that this year?

Caitlin, it's Jim. I'll take that one. I think as Tony just said, our contracting focus while we continue to drive a focus on the RTM category, especially into site level agreements, the team has done a really nice job in 2025 of getting many of those agreements signed, 2026 is an execution year. We have to translate that, move it through the hospital processes, where we have a lot of surge in advocacy. We have to work it through the admin process and translate that signature now into patients and revenue.

Yes. I think as new opportunities present themselves, such as Vizient, that's been delayed. We're certainly going to go for that, but we have more than enough footprint that we have to start executing on, as Jim said, before we just continue to drive agreements. I mean we'll continue to do both, but we have to focus on execution within the agreements we have.

[Operator Instructions] Our next question comes from the line of Frank Takkinen from Lake Street Capital Markets.

I wanted to follow up on the Q1 guidance a little more. Obviously, I heard all the comments about the structural changes you've made with the commercial organization and the disruption that has caused. But I was just curious if there was anything else specific to call out with Q1. I know typically, the seasonality is kind of up a few percent or down a few percent in some instances depending on the year, but just the double-digit down quarter-over-quarter, curious if there's anything beyond the sales force comments you've made going on Q1?

I'll start, Frank. I think my whole monologue on prudence for the year is transferable to Q1 as well. I think we have one dynamic that I think has added to the general slow start that you see in hernia and plastic and reconstruction, which is typical in January and February. And that is -- which I didn't mention before, is part of what Jeff and Jim has done is the territories have been restructured to be smaller, right, to go deeper, which means there's been some splitting of territories. And what we're encouraging is sales force efficiency, right, which will help from time spent selling to T&E expense. And we are going to concentrate density of reps in smaller areas, preferably adjacent to high population areas that are already successful with us. So that means we may abandon a little bit of the hinterlands and the smaller hospitals that are out in the perimeter, not fully abandoned, but deemphasize a little bit. So that's going to cause a little bit of -- a little bit of loss as we go through these shifts of splitting territories and creating more efficient density in the network. So we wanted to make sure that we gave ourselves some room to work through that, which should mostly be taken care of through the end of the first quarter, and we should start to see some signals that we're coming out of that transition phase in Q2. Does that make sense, Frank? That's in addition I think.

Yes. That's perfect. I appreciate that. And then...

This is Jeff Blizard. I just want to add one more point on to Tony. And the word disruption is something we've avoided here. And we didn't call this a reorganization. Really the focus has been on restructuring, right people and right roles and making sure that we can have a focus on these key customers in key cities and also those academic programs that are hub in key cities. What we found in not only the challenges in January that most companies were facing was over 1,000 square miles of geography in the U.S. was impacted by that blizzard, and we saw a number of electric procedures be impacted by that. So we've heard that from other programs and other companies that have had similar situations.

Yes, that's helpful. And then as we think about exiting this period where we're maybe returning to a steady state growth rate, how do you view the steady-state growth profile of TELA over a longer period of time?

Yes. Well, I think the markets that we serve are kind of mid-single digits. We've been above market rate growth since inception. And I think we anticipate that we will be able to significantly outgrow the market. And the other interesting thing, I think, as you look at the data that we're presenting here is that our units for both PRS and hernia are high, right? Our growth rate on the hernia units, I think, is 20% or 22%? 22%, right? So that's a very good sign for the long haul, given that, that's the bulk of the procedure. So making inroads into those smaller piece procedures is super important. It does have an impact with mix shift and top line revenue, but that should straighten out as well. We certainly believe that once we get to steady state, we should be back into the double-digit growth or beyond. This is the way for us to give ourselves -- to clear the decks, we've never done a change this comprehensive that affects territory planning, compensation plans to drive that this is so comprehensive. We're just giving ourselves the room to get back to that double-digit plus growth. I think we have a great shot at getting there in the second half of this year, hopefully.

Got it. That's helpful. And then if I could just squeeze one more in. As it relates to your point on unit growth, that's been really solid, obviously, in both product categories. What's your latest thought on how we should think about when ASPs and hernia could start to flatten out and stabilize?

Yes, that's a good question. I'm just looking -- I was looking at that before the call to prepare. And one of the metrics I look at is what type of hernia procedures we're doing, right? I think for the longest time, we were about a 70% ventral company. And that is shifting. And I think we always had about 10% to 15% of inguinal. But right now, I'm just thumbing through it, I'll go by memory, and Jim can correct me if I'm wrong, but I think we're at about 50% of our business right now is ventral. And 25% of our business is inguinal. 14% is hiatal. So we were really a 10% to 14% company on both inguinal and hiatal when we -- in the past before this shift of getting more involved in the fat part of the bell curve of hernia procedures. But now we're already up to -- we're down to 50% from 70% on ventral, and we're up from 10% to 12%, inguinal up to 25%. So it's hard for me to say where that balance goes. There's almost 1 million inguinals done a year. So we're going to keep mining that until we hit some kind of a steady state, right? So it's going to have to do with the mix between inguinals and ventrals.

The other comment I would say on this one, Frank, is not just the type hernia but the modality of the procedure as we see procedures moving away from opens into laparoscopic and robotic procedures. We're well positioned. That's also why you see our LPR portfolio outpacing much of our growth, along with IHR. So I do think surgeons are voting with their preferences using us more where procedures are going, which is laparoscopic and robotic for us. So that ASP shift to Tony's point, is going to continue. We're going to continue to see more of our volume moving to those lower pieces with an ASP, that's a bit lower than we've historically had been with the large opens. But as I think Roberto will continue to remind everyone, that does not impact gross margins.

Yes, just to put a little finer point on it, Frank. What we're seeing is we're seeing the start of robotic surgery starting to make more and more inroads into the open complex cases. And so we're there, ready to serve those cases beautifully with our LPR product, right? And certainly, our inguinal product is robot compatible as well. So we're well positioned for how the hernia market is evolving. How long that takes? It's hard to say. But I do think the future is going to be higher unit growth volume, more procedures, but smaller pieces. And I think you're going to start to see our 1S, 2S and Core start to give way to inguinal and LPR. And hopefully, in the future, LIQUIFIX as being the main unit drivers going forward. But we'll certainly get all the opens that we can with our older portfolio. And one more thing to add. I'm sorry, a little stream of consciousness here, but the long-term resorbable hernia product has 0 permanent polymer in it. And a lot of these old time surgeons do have analogy to putting anything permanent. I mean our product works beautifully in these cases and many, many surgeons do. But there's just some category of surgeon that wants nothing permanent. So our long-term resorbable product, I think, has a shot of opening up some of those more difficult complex trauma, complex ab wall cases down the line in the future, but that remains to be seen. But I think the global trend is towards robotic for everything and smaller pieces, which favors our LPR product portfolio.

And our next question comes from the line of Michael Sarcone from Jefferies.

Just a follow-up on one of the first questions and not to belabor this, but when you provided that kind of at least 15% directional outlook in mid-November. You mentioned there was some built-in cushion in there. Just trying to get a better sense for what changed to understanding you're trying to be even more prudent and you want to derisk the guide. But did anything else change over the last 3 months around expected rep productivity ramp or anything like that? Just trying to get a bridge from the 15% to the 8%.

Yes. Michael, it's Jim. I'd say one of the biggest thing is really the tenure Jeff and I had in role. We started in June. We had that call in the fall. We were in the midst of the change. I think what we've learned since then is it was a sizable change. There were multiple things we put on the field organization at the same time, while we concurrently we're hiring rapidly into the organization. So I would say our assumptions changed from when we had the Q3 call to now, just appreciating the change curve it takes to move an organization through all of that is a bit longer and more complex. I think that when we originally planned it out, it's not saying it's not going well. It's actually going very well. But the prudent point to Tony is we are going to give ourselves some more time to work through that change curve, get new reps up to speed and up to efficiency where we need them through and get our legacy team in the U.S. kind of through that change curve of new leadership, new comp plan, new territory alignments, so everyone is then hitting full stride hopefully, in the second half of the year.

Got it. That's very helpful. And then maybe just one on the new kind of account targeting strategy, you talked about deeper penetration in existing accounts. Can you talk to us about some of the methods that you plan to use to broaden out that penetration in existing accounts?

Sure. It's Jeff. So with the problem statement that we analyzed over the last few months was too many reps were dependent on one surgeon in one location. And for us to, we talk about terms like stickiness to our business. In order to do that, especially larger programs that have anywhere from 3 to 7, sometimes even 9 general surgeons or multiple plastic surgeons per site, we couldn't rely on just 1 user. With the way that the comp program was set up and the goals and objectives in 2025, the need for our territory managers to be spread far and thin was so that we could gain distribution and they could work their comp program to the best of their ability. And we realized that was a limiting factor. That meant product was in hospitals without patients being covered. And that meant users were identified without another person on staff that had bought into the product or the proposal that this was a better device or product than the ones they were using. Having this as a focus point allows us to do better in servicing teaching and training programs, how to handle the product, being present and being bedside so the patients can receive optimal outcomes. And then compensation plan was built around that specifically, smaller geographies as opposed to we have reps that were driving in the car, 3 to 5, sometimes even 6 hours in the great state of Texas, that they found themselves racing across the state to deliver product to be present for that 1 physician and that 1 program. So we know that this density rule will work as well as having in those -- many of those large cities, as I mentioned earlier, an academic hub, where now we can put people in to help support our fellows and our residents that are being trained in this next-generation surgeons.

Michael, the only thing I'll add to that in terms of how we're doing this is leveraging the full portfolio. As we just talked about on Frank's conversation, we grew historically through large open procedures of 1S and 2S. As we think about building depth within a hospital, we're talking about more users within that specific site. LIQUIFIX, as an example, gives us a new opportunity to engage a surgeon who may not fully believe in OviTex but wants an alternate fixation technique. That's a new in for us. Driving IHR and LPR, go after those surgeons who are more proficient on the robot or focusing on the robot. So our portfolio allows us to engage with more users within a specific hospital, and that's what we're asking our field team to do is leverage the full bag, drive more users per site, and that's one of the key metrics we're going to measure them on this year, that creates the stickiness for us and that it allows us to go after the higher ceiling accounts and drive a deeper share within those accounts, which for us, to Tony's point, that ability to have a more predictable top line revenue, that's part of that formula.

Yes. And I'll just put a fine point on the end of Jim's comment. If you're wide and shallow and you got 1 surgeon 4 hours away, who's using your product, it's pretty easy to dislodge that surgeon, right, from his usage habit and patterns when you're not present fully and you got competitive reps looking to lever you out with contracting and rebates, we have to get 5 and 6 users in a smaller geography. That is really what we're setting ourselves up to do. You become much harder to knock down.

And our next question comes from the line of Matthew O'Brien from Piper Sandler.

I don't know, Roberto or if somebody else can maybe talk a little bit about the impact of weather in Q1 because the number is so low versus what we were kind of expecting. And I get it's Q1 and everything and you're still going through this transition. But it's just so low that it requires you to start putting up some numbers in the -- especially in the back half of the year that we haven't seen out of the company, it requires a lot of faith that you can be able to do that. So maybe just talk about those 2 components there, the weather impact in Q1 and then what you're seeing that gives you confidence that should give investors confidence that the back-end loaded guide is achievable? And then I do have a follow-up.

Matthew, it's Jim. I'll take the first half of that. So the it's 2 variables external to us in Q1. We're trying not to focus on external variables, but they are real sometimes. One, feedback from our field team is just volumes in January were low, right? So I think there was just a market low coming out of the holidays with -- I'd say, interest premiums resetting. That was a real impact. And as Jeff talked about, the impact of the storms on the East Coast with major population density did shuffle some elective procedures, some were lost, rights were not happening. Some others got deferred out past Q1. We don't have, I would say, firm guidance for you on kind of what percentage impact that had to us. Now what we are trying to focus on is more of what our controllables were in Q1, which is really where we spent that time on hiring, getting new people into the organization, getting them trained up and going along with what we just talked about is that mix shift from shifting accounts from lower ceiling accounts and kind of lower density areas to higher ceiling accounts in more populous areas. I would say that probably had a more material impact for the performance in Q4 to Q1. Those are the things we can control, and that's where I think where our focus is.

Yes. And Matt, we have snapped back quite well after 4 quarters, right? I think it was Q4, right, we had a little bit of a [ rate ] on our sales force, and we snapped back very effectively in Q1 of '25. So I think we've got enough factors of safety built in with the new product launches, having a fully staffed sales force at 90 reps -- or a little over 90 reps in the next couple of weeks here. We've never been at that scale, and we've never been fully to our hiring plan this early in the game and that's by design. And then I think the talent of the reps, getting them through that 6 months bed-in period where they get productive. There's a lot of factors that are going to help us and give us tailwind in the second half of the year.

And Matt, with regard to the back half versus first half and confidence with that -- with regard to that, we have always grown quarter-to-quarter across the year. We have built our quotas and expectations for our existing reps, our tenured reps and for new reps based on that sort of growth. So even if we have not added the number of reps we did in the first quarter, we would have expected to see growth across the year that would have led to that step up from the first half to the second half, that will be amplified by the addition of these new reps who are going to hit breakeven in about 6 months and then start breaking through and becoming meaningfully productive in that second half.

Yes. You have to remember, it's 40% of our sales force has been on board for less than 6 months. So -- and these are high-quality reps that we've hired, and we're going through the process now of getting them bedded in and up and running.

Okay. Appreciate that. And then a follow-up is on -- and I'm just -- I'm trying to square all the different numbers here between the LIQUIFIX and the OUS growth in the quarter was actually really good. I want to start to carry that forward. I start to get some softer OviTex numbers for the full year kind of versus what you've been doing? And not sure that makes a lot of sense just given the sales force expansion. And yet, I know you want to be conservative. It just -- it leads you to the conclusion that there's something else going on that isn't quite squared away yet. So I don't know if there's a way you can kind of walk us through what you're expecting OviTex versus PRS versus other revenue in OUS, but just help me understand how this -- how the different product lines are going to play out here in '26?

I'll start and -- it's Roberto. I'll start and I'll let Jeff and Jim jump in and Tony. So one thing to remember is that Europe is purely OviTex sales, purely hernia sales. So as we get solid growth from Europe, that's going to -- that's all going to be dropping to the "hernia bottom line." We do expect to see PRS sales grow over the course of the year. in part from the launch of larger pieces and potentially new technologies. So it's not that we see either one of those softening up and we expect to see LIQUIFIX continue to grow strongly, although it's going from a much smaller base, so it will have a smaller revenue line impact. But I'll let Jeff and Jim add anything to that.

Yes. I think we're blessed with AMS' focus on us as a partner. They've made a huge investment in their clinical team to help us with product evaluations and trials. They have done -- they've matched us as fast as we're trying to get our organization set so have they. I would say that with this focus we have, and we teased a little bit about it in our last quarter earnings, that we're headed towards an academic program. That's brand new to us in 2026. So having the right leader, who we have in Marissa Conrad focused on that, having a partner with AMS. That drives that product adoption in the general surgery residency and fellowship program as well as the plastics. That's all, again, new and then considering what the back half of this year, it looks like for new product launches as well as not necessarily any more organizational disruption that came earlier from you guys, but more as nuance changes always adapting and changing with the business that when they identify needs we solve for it.

Yes. Matt, I think what you're saying is you're looking at all the potential growth drivers and it doesn't make sense that our OviTex business would grow less. So I'm just going to sum it up and just stick with the word prudent, give us a chance to metabolize these territory changes, the new reps, the new products, all of it prudence. I don't see the hernia or PRS business collapsing in any way.

This does conclude the question-and-answer session of today's program. I'd like to hand the program back to Tony Koblish for any further remarks.

Thank you, Jonathan. Yes. Thank you. So the changes we made were thorough. I hope you got a sense of that. We've never cleared the decks to this level, right? I think in the past, the changes have been a little from this place, a little from that piece, incremental because we're striving to go wide and make numbers, right? So we're taking a step back from that to recast this in absolutely the right way across every dimension, whether it's comp, focus, population density, rep density, everything. And I think we had it set up correctly for the long haul. There's going to be much less disruption from this point forward. We have it locked in the way we want it now, the way Jeff and Jim want it. And now we just got to operate the machinery in the right way. So we really appreciate your interest, stay patient, and we look forward to what's ahead.

Thank you, ladies and gentlemen, for your participation in today's conference. This does conclude the program. You may now disconnect. Good day.