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Healthcare - Medical - Devices - NASDAQ - US
$ 1.26
-2.33 %
$ 47.4 M
Market Cap
-1.54
P/E
EARNINGS CALL TRANSCRIPT
EARNINGS CALL TRANSCRIPT 2020 - Q2
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Operator

Good morning, ladies and gentlemen, and welcome to the Second Quarter Fiscal-Year 2020 Earnings Conference Call for Apyx Medical Corporation. At this time, all participants have been placed in a listen-only mode. At the end of the company’s prepared remarks we will conduct a question-and-answer session.

Please note that this conference is being recorded and that the recording will be available on the company's website for replay shortly.

Before we begin, I would like to remind everyone that our remarks and responses to your questions today may contain forward-looking statements that are based on the current expectations of management and involve inherent risks and uncertainties that could cause actual results to differ materially from those indicated, including those identified in the Risk Factors section of our most recent annual report on the Form 10-K filed with Securities and Exchange Commission, as well as our most recent 10-Q filing.

Such factors may be updated from time to time in our filings with the SEC, which are available on our website. We undertake no obligation to publicly update or revise our forward-looking statements as a result of new information, future events or otherwise.

This call will also include references to financial measures that are not calculated in accordance with generally accepted accounting principles or GAAP. We generally refer to these as non-GAAP financial measures.

Reconciliations of those non-GAAP financial measures to the most comparable measures calculated and presented in accordance with GAAP are available in the earnings press release on the Investor Relations portion of our website. I would now like to turn the conference over to Mr.

Charlie Goodwin, Apyx Medical's President and Chief Executive [ph] Officer. Please go ahead, sir..

Charlie Goodwin

Thanks, operator. Welcome, everyone, to our earnings call for the second quarter of 2020. I am joined on the call this morning by Tara Semb, our Chief Financial Officer. Let me provide you with a quick agenda for today's call.

I'll begin with the review of our revenue results for the second quarter, including a summary of the impact of the COVID-19 pandemic on our second quarter results.

Following this discussion, I will provide you with an update on our recent operational highlights and progress we have made on the four initiatives we are pursuing as part of our longer term growth strategy. Tara, will then provide you with a detailed review of our second quarter financial results.

Following Tara’s remarks, I'll conclude by sharing some thoughts on our near term and long term outlook before we open the call for questions. With that, let's get started with a review of our revenue results. We reported total revenue of $4.3 million for the second quarter of 2020, representing a decrease of 35% year-over-year.

From a geographic standpoint, our total US sales for the second quarter of 2020 decreased 25% year-over-year to $3.4 million, while our total international sales decreased 57% year-over-year to $0.9 million. In terms of revenue performance in each of our business segments.

In our Advanced Energy business sales decreased 46% year-over-year to $2.9 million. In our OEM business sales increased 10% year-over-year to $1.4 million. The sales growth in our OEM business was driven by higher sales to our legacy OEM customers, compared to the second quarter of 2019 due to timing of orders.

As anticipated, the revenue performance in our Advanced Energy business was significantly impacted by the COVID pandemic and the actions taken to slow its spread. As discussed on our first quarter earnings call, the vast majority of procedures performed with our Helium Plasma Technology are elective.

During the second quarter many of our cosmetic surgery customers around the world continue to be affected by government actions requiring elective procedures to be postponed and non-essential businesses to close temporarily, which resulted in slower adoption and utilization.

Specifically, the 46% decline in total Advanced Energy revenue in Q2 was driven by a decline in generator sales of 60% year-over-year, and a decline in handpiece revenue 15% year-over-year. While Q2 was undoubtedly challenging, we were pleased to see improving trends in each month as we progressed through the quarter.

We saw the largest impact from COVID in April, with total Advanced Energy sales decreasing 93% year-over-year, driven by declines in both the US and OUS markets.

In the US, where nearly all Renuvion procedures are performed in outpatient facilities, such as doctor’s offices and surgery centers, we estimate that virtually all of our customers offices were temporary closed throughout the month of April, as a result of state and local restrictions.

After a difficult month in April, signs of recovery and trends started in May. Specifically in May, we were encouraged to see many of our US surgeon customers reopen, as restrictions on elective procedures and non-essential businesses began to be lifted in various regions across the US.

As of the end of May, we estimate that roughly 70% of our US customers had reopened. As US practices reopened, our customers were focused on rescheduling postponed or canceled procedures from late March and April, many also reported building strong pipelines fueled by successful implementation of virtual consultations, while offices were closed.

We saw procedure activity increased steadily in May and June, and we're particularly encouraged to see utilization based-demand for our Renuvion handpieces follow. Specifically, Renuvion handpiece demand increased nearly 80% year-over-year in the month of June.

In one of the most challenging quarters for a medical device manufacturers, especially those with elective procedure exposure, the number of Renuvion handpieces sold in the United States declined less than 2% year-over-year.

The utilization based-demand for Renuvion handpieces continues to demonstrate that our system is not one of the many examples of the aesthetic market technologies that are adopted and rarely used.

Instead, the continued demand for our handpieces is the clearest example, that our cosmetic surgery customers have incorporated Renuvion into their practice, value the strong clinical efficacy and compelling patient outcomes and appreciate the strong return on investment that the system offers to cosmetic surgery practices.

Turning to a brief discussion on our Advanced Energy business outside the United States. Unfortunately, the COVID related business disruption in our primary markets was more pronounced than what we experienced in the US during the second quarter.

It is hard to characterize the relative improvement of our OUS business overall, as the pace of recovery outside the US has varied depending on the region. April was a very challenging month as a result of COVID related restrictions on elective procedures.

We did see business trends improved during the quarter with May better than April and June showing a very modest improvement in business trends compared to May.

While the OUS us environment was extremely challenging in Q2, the progress we made towards one of our strategic growth initiatives in Q2 helped offset some of the COVID related headwinds in the quarter.

As I will discuss in more detail in a minute, we recently secured a new product registrations authorizing the sale of our Helium Plasma Technology products in five new countries.

We shipped initial orders to two of these countries, Brazil and Australia, which helped offset some of the year-over-year decrease in our international Advanced Energy sales in Q2. Simply stated, Q2 was a difficult quarter for our business, as anticipated given the fact of COVID-19.

April represented a very challenging start to the quarter for our global Advanced Energy business, with total global Advanced Energy sales declining 93% year-over-year.

In the US, we saw material improvement in business trends, the latter half of the second quarter, while we were encouraged by the 80% growth in handpiece sales we saw in June, they were only partially offset the challenging capital equipment environment and our US sales were down 30% for the month of June.

Outside the US, q2 was particularly challenging, but we were pleased to see the impact of COVID offset partially by the initial orders to Brazil and Australia. We were certainly happy that the quarter ended on such - on a much stronger note than where it began.

However, our total Advanced Energy sales for the month of June still declined 18% year-over-year, and demand trends for generator adoption in both the US and in our primary OUS markets reflect a market that is in a very early stages of recovery. Turning to a discussion of our operational progress during the second quarter.

Despite the COVID related disruption experienced during the second quarter, we continue to make progress with respect to the four strategic initiatives we are presuming to position Apyx Medical for long term growth in the cosmetic surgery market. I'll take a moment to review our recent progress with respect to each.

Starting with our first initiative to pursue specific clinical indications that will enable us to market and sell Renuvion for new targeted procedures. In the US as a reminder, we are conducting two IDE clinical studies designed to support our pursuit of new indications for use in Dermal Resurfacing and Skin Laxity Procedures.

As discussed on our Q1 call, clinical trial activity across the US was significantly impacted by the disruption created due to COVID-19 beginning in March. Up to that point, enrollment in both of our IDE clinical studies had been progressing, but was paused as a result of the COVID related disruption.

In response, our clinical team was focused on working closely with the investigators from both studies to help mitigate the impacts of this disruption. Once restrictions on elective procedures were lifted in May, we were pleased to resume our efforts in both clinical studies.

Despite the COVID driven delay, things are progressing now in both our IDE Dermal Resurfacing study, and in Phase 1 of our IDE Skin Laxity study, which is focused on one month safety data.

Outside the US, our regulatory strategy has focused on expanding our commercial footprint by obtaining regulatory clearance for our Helium Plasma Technology in new countries. As part of this strategy, we are focused on owning the product registrations in the countries that we enter.

Our team continued to make important progress on this front during the second quarter, as a result on June 22nd, we were excited to announced that we received regulatory approval to market and sell our products in five new countries, Australia, Brazil, Israel, Taiwan, and Thailand.

While we expect the addition of each of these countries to benefit our longer term growth profile, its important to note that Brazil represents the second largest cosmetic surgery market in the world, both in terms of total number of procedures performed and the number of surgeons.

During the second quarter, we shipped initial commercial orders to our distributors in Australia and Brazil, and we expect to ship initial orders to the remaining three countries during the second half of the year.

In connection with our second strategic initiative, we continued our efforts to expand our portfolio of clinical evidence supporting the use of our Renuvion technology. In April, we published a manuscript discussing the results of our first US IDE study on Dermal Resurfacing in the peer-reviewed journal, Lasers in Surgery & Medicine.

In addition to this publication, our team continues to make progress on additional clinical manuscripts. And we expect to complete and submit multiple manuscripts for publication during the second half of 2020. With respect to our third strategic initiative, enhancing physician and practice support for our cosmetic surgery customers.

During the second quarter, we shifted our approach to educational programming and began hosting events virtually for the benefit of both current and prospective customers around the world. In the US, our sales and marketing and field clinical teams hosted four virtual physician education events, which drew close to 200 physician attendees.

These events included webinars, where our leading physician customers discussed a variety of topics, including the factors that drove their decision to adopt Renuvion, their experience with the technology, their strategies for marketing the technology, and their thoughts on pricing and return on investment.

Outside the US, our team hosted continuing educational training sessions on J-Plasma and Renuvion with our current international distributors. They also conducted calls with groups of international prospects interested in learning about Renuvion technology.

Lastly, let me briefly discuss our fourth strategic initiative, improving our manufacturing capabilities and efficiencies. Our work to identify and implement new lean initiatives continues to progress and remains an important area of focus for our organization, helping us realize continued improvements over the coming years.

As a reminder, one of our focus areas with respect to this initiative has been to implement new process improvement in order to reduce the per unit manufacturing cost of our Advanced Energy products. We have begun to see early evidence of these activities in the form of improving handpiece margins.

Given our progress towards this initiative, we continue to move forward with the APR handpiece as our primary Renuvion handpiece.

While this decision resulted in a near term P&L impact related to the writedown of prior generation handpiece inventory in Q2, we expect considerable contributions to our longer term profitability as the APR handpiece becomes a larger portion of our total handpiece sales going forward.

This is a clear example of how the progress we are making towards our strategic initiatives is enhancing our long term growth and profitability profile.

Stepping back, despite the impacts of COVID pandemic, I am very pleased with our company's financial and operational performance this quarter, and the excellent job done by our teams under these challenging circumstances.

With that, let me turn the call over to Tara to discuss our second quarter financial results and comments made in our earnings press release this morning.

Tara?.

Tara Semb

Thanks, Charlie. I will begin my review of our financial results across the rest of the P&L, as Charlie covered our second quarter revenue performance in detail. Gross profit for the second quarter of 2020 decreased $2.6 million or 55% year-over-year to $2.1 million.

Gross profit margin for the second quarter of 2020 was 48.7% compared to 70.3% last year. Our GAAP gross profit in the second quarter of 2020 was impacted by inventory writedowns during the period.

We reassessed our forecasted product mix, due to COVID-19, increased the availability of our newest - newer handpiece designs, and benefited from earlier than expected completion of product registrations in certain international markets.

As a result, certain products were reduced to a lower carrying value and some components were also written-off, as it was determined to cease further production of these models. This resulted in an increase in GAAP cost of goods of approximately $0.4 million during the second quarter of 2020.

Excluding the increase in cost of goods related to inventory writedowns, the year-over-year change in gross profit margin for the three months ended June 30, 2020 was driven by product mix within both our Advanced Energy and OEM segments, revenue mix between our segments, three geographical revenue mix, and improved product margins in our Advanced Energy segment, as a result of our continued manufacturing efficiency initiatives.

Operating expenses for the second quarter of 2020 decreased $0.8 million or 9% year-over-year to $8.3 million, compared to $9.1 million for the second quarter of 2019.

The decrease in operating expenses year-over-year was driven by a $0.8 million decrease in selling, general and administrative expenses, and a $0.1 million decrease in salaries and related costs, partially offset by a $0.1 million increase in research and development expenses.

Importantly, the decrease in operating expenses reflects our initiatives to control costs and reduce our discretionary spending and respond to the impact of COVID-19 on our financial condition.

Specifically, our operating expenses decreased 21% quarter-over-quarter, as a result of our proactive efforts to control costs in the more challenging operating environment. Loss from operations for the second quarter of 2020 was $6.2 million, compared to operating loss of $4.4 million last year.

Income tax benefit in the second quarter of 2020 was $1.5 million, compared to income tax expense of $76,000 in the second quarter of 2019. In the second quarter of 2020, we benefited from a GAAP tax benefit related to the CARES Act, which was enacted by the US government to provide relief from the corona virus pandemic.

As discussed on our Q1 call, the CARES act includes a net operating loss or NOL, carryback provision, from which we expect to receive a cash tax refund of approximately $3.7 million by the end of 2020. We recognized an income tax benefit of approximately $1.4 million in the second quarter of 2020, which reduced our GAAP effective tax rate.

Net loss for the second quarter of 2020 was $4.7 million or $0.14 per share, compared to a net loss of $4.3 million or $0.13 per share for the second quarter of 2019. Second quarter 2020 adjusted EBITDA loss was $4.9 million, compared to an adjusted EBITDA loss of $3.6 million last year.

Excluding the increase in cost of goods related to inventory writedowns in the period, our adjusted EBITDA loss increased only 22% over year – year-over-year compared to a 35% decrease in total revenue year-over-year.

Our Q2 adjusted EBITDA loss decreased 23% quarter-over-quarter, which represents the company's proactive efforts to lower our OpEx during the challenging operating environment. As a reminder, we provided a detailed reconciliation from GAAP net loss to adjusted EBITDA in our press release this morning.

As of June 30, 2020, the company had cash and cash equivalents of $46.2 million compared to cash and cash equivalents of $58.8 million as of December 31, 2019. The company had working capital of $60.2 million as of June 30, 2020, compared to $64.4 million as of December 31, 2019.

Lastly, as mentioned in our earnings press release this morning, given the ongoing challenges and uncertainties posed by the global COVID-19 pandemic, the company will not be providing full year 2020 financial guidance on today's call.

Assuming a more normalized business environment prevails at the time of our third quarter results conference call in November, we plan to provide updated expectations at that time. With that, I'll turn the call back to Charlie for closing remarks.

Charlie?.

Charlie Goodwin

Thanks, Tara. As Tara mentioned, the timing of returning to normalized operating environment remains highly uncertain. Given this uncertainty, in July we continue to monitor the business trends and solicit feedback from our customers to determine the ongoing impacts of the pandemic.

We saw promising trends in the market where nearly all of our existing customers were open as of the end of June. The feedback we received from our US customers in July indicated that they were very busy working to accommodate the backlog in cases caused by the COVID pandemic.

Accounts have reported extending their office hours or adding additional days to their schedule in order to accommodate these cases.

Interestingly, some accounts that perform consultations virtually during the second quarter mentioned that they have continued this practice to some extent, in order to free up more of their time in the office to perform procedures.

By all accounts, July was a very busy month, and for our clinician customers in the US, fueled by strong backlog of cases that were rescheduled from late March and April, and a strong pipeline of procedures.

While procedure volumes have been challenged in some areas of the country that are COVID hotspots, overall, we continue to see strong demand for our Renuvion handpieces from customers in the US cosmetic surgery market in July. On the capital equipment front in July, we saw some initial signs of improving generator adoption in the US.

However, the recovery and capital equipment purchasing remains in the early stages overall, and the timing and cadence of the recovery in the capital equipment demand remains uncertain. Outside the US in July, we saw some limited improvements in handpiece demand, and pockets of relative strength in some regions.

However, the demand for handpieces in our primary markets continues to lag behind the trends seen in the US, and the overall purchasing environment for capital equipment remains in the very early stages of recovery.

We appreciate the high level of focus from the investment community on understanding how companies are faring in the early stages of the recovery from the global pandemic. In the interest of transparency, we are providing current quarter details that we otherwise would not include in our quarterly disclosures.

To that end, in addition to the commentary on the business trends that we have seen in the first month of Q3, we are also reporting that our Advanced Energy sales in July increased 35% year-over-year, driven by strong growth in the US and negative growth outside the US.

We are obviously pleased that our year-over-year Advanced Energy sales trends reflect growth in July, compared to declines in June. However, we would highlight that this growth performance benefit from a softer prior year growth comparison.

More importantly, we are still uncertain as to how much of the recovery in our sales trends has been driven by backlog related purchasing versus a true reflection of a return to a more normalized operating environment, which is the key leading indicator for sales of generators going forward.

At this point, we believe it is more likely the former, and thus we remain cautiously optimistic that we will see continued improvement in our Advanced Energy business trends as we progress through the second half of 2020, with hopes of returning to year-over-year growth in the fourth quarter.

With respect to a near term outlook for our international Advanced Energy business, as discussed, it remains highly uncertain, and we are hoping to see trends improve over the second half of 2020 such that the business trends improve enough by year end to begin returning to growth year-over-year in early 2021.

Ultimately, while the timing of a return to a more normalized environment remains highly uncertain, we are well capitalized to weather the ongoing effects of this pandemic and well positioned to execute our growth strategy as the recovery progresses.

We have been proactive by controlling our costs by reducing discretionary spending, implementing hiring freezes and delaying investment in certain R&D projects and clinical studies until they can be efficiently pursued under a more normalized environment.

The resulting environment in our operating expense profile was a material contributor to our financial performance during the second quarter, and is expected to benefit our results in the second half of the year as well.

At the same time, given our strong balance sheet condition, we have continued to invest in areas of our business that represent key elements of our growth strategy. Most importantly, we continue to maintain the size of our sales team, which remains focused on engaging with both existing and potential customers using virtual means when necessary.

We also continue to invest in our four strategic initiatives that I discussed earlier, which will position us to drive long term growth in the cosmetic surgery market by facilitating the broad based adoption of our technology.

As we enter the second half of 2020, our organization continues to demonstrate their ability to support our customers and execute our long term strategy despite the ongoing challenges of COVID pandemic. Going forward, we will remain intently focused on these objectives, as we position Apyx Medical to return to our prior track record of growth.

With an estimated $1.5 billion addressable market opportunity in the US alone, and recently expanded addressable market opportunities outside the US, we continue to believe we are uniquely positioned longer term to drive sustained growth for many years to come.

As the post COVID recovery takes shape, we look forward to continuing to expand our market share and elevate the global cosmetic surgery market with our transformational Helium Plasma Technology for the benefit of our surgeons, patients and shareholders.

In closing, I'd like to offer a special thanks to all of our employees for their hard work, flexibility and commitment to our success, which makes me proud to be a member of the Apyx team. I'd also like to thank our distributors, customers and shareholders for their continued support, and those on this call for their interest in Apyx Medical.

With that operator, let's now open the call for questions..

Operator

Thank you. [Operator Instructions] And our first question will come from Matt Hewitt of Craig-Hallum. Please proceed with your question..

Matt Hewitt

Good morning, and thank you for taking the questions..

Charlie Goodwin

Good morning, Matt..

Matt Hewitt

First one, is there any way to - and I know April and May, it's probably not worth getting in too far into that.

But when you look at June and July, where you are seeing pretty rapid recovery, is there any way to parse out how much of that was working through backlog of procedures that have been cancelled versus new demand?.

Charlie Goodwin

Yeah, Matt. You know, in April, like we mentioned, virtually all the customers were closed. We started to see recovery in May, and customers were doing virtual consultations and getting their practices back to order.

And as we got into late June, nearly all the customers were open as of June and the activity in the offices in June and particularly July have been very strong. And, we were obviously in June encouraged to see the utilization demand up nearly 80% year-over-year. And those trends were still strong in the month of July.

And, you know, in one of the most challenging quarters of med tech history, our handpiece growth was just down 2% year-over-year.

And so, we continue to see that they're very busy, but we're just unsure at this point in time and that's why there's a little uncertainty as we go forward here into the third quarter, about whether this is real demand or just driven by the backlog.

The great thing is that our customers are extremely busy, and we just need to continue to see if that will continue or not. And at this point in time, I don't know that we've got a great answer for you there..

Matt Hewitt

That's all right. I understand. And maybe a follow-up question. Regarding the capital equipment, obviously, there's some delays there in purchasing completely understandable.

What do you think will be the trigger both domestically and internationally for those customers just to come back and start buying capital equipment? Is it just simple dollars in sense when they've gotten through their backlog and they feel comfortable that things are going to stay open? Or is there something that you could do maybe from a marketing perspective to help them adopt the technology a little bit earlier?.

Charlie Goodwin

Yeah. So look, we obviously have a lot of programs for them right now to help them. But I think the bigger issue for them quite frankly, is just what do they think is going to happen with the virus in the back half of the year? And I think it is - it's as simple as that.

You know, we've got lots of programs that we can help them adopt our technology if necessary, but I think they in their minds, each person's individual, they would like to have some form of confidence about what the virus is going to do in the second half of the year, because obviously, that affects their business in a great way, whether they're going to make a capital investment or not..

Matt Hewitt

Got it. Thank you..

Charlie Goodwin

Thank you..

Operator

The next question is from Matthew O'Brien of Piper Jaffray. Please proceed with your question..

Matthew O'Brien

Morning, Chad. Thanks for – good morning, Charlie and Tara. Thanks for taking the questions. You know, maybe just a little bit more on some of these hotspots. I'm curious how your customers are adjusting right now to mitigate the risk of any potential impact of some of these outbreaks that we're seeing around the country.

I mean, it's a very - pretty big state. So what are they doing to make sure that we don't go through another, you know, big round of shutdowns.

And then on those virtual events that you talked about, this 200 individuals that you saw, how many of those were new versus existing customers?.

Charlie Goodwin

Yeah, so for the hotspots, look, the big advantage that we do have where these procedures are done, is they are done in the doctor's office setting or in a small surgery center that they typically own. And so, fortunately for us, the patients in the United States anyway aren't having to go into a hospital and be subject to that.

And so the good news for our clinicians is that they control the environment and can you know, space out patients appropriately, whether they have them wait in their car until the next one comes in, it totally depends on the clinician, the state, the guidelines, all of that kind of stuff. So it's a little bit all over the board.

But the good news is, is that they themselves have control over how they keep their patients safe. And from what we understand the vast majority obviously are doing a great job, if not all of them. I haven't heard anything of the contrary for that.

So that is that is an advantage that they can that do that and they're in control of the situations themselves and are having to rely on bigger institutions where there's a lot more people and all of that kind of stuff. So that part is encouraging from our side.

As far as the 200 clinicians and how many of them are brand new versus not, I would say the vast majority of them are new prospects or new clinicians. For the types of events that we've been having to have a customer that already owns the technology on there to listen to it, there's not a lot that they're going to get from these type of events.

And so the 200 that we were speaking to there, for the most part, the vast majority of them would be new clinicians..

Matthew O'Brien

Okay. That's really helpful. And then as the follow-up, you talked about these five new countries, obviously, Australia and Brazil are large opportunities. I think Brazil is generally soft right now.

So can you talk about how - you know, if you can add to sum up the opportunities of those five new countries, how big would all five of those be? And then when can they be meaningful contributors from a, you know, recurring revenue perspective, I know you had some one-time sales here and there are some stock in sales here in Q2.

But more, you know, more contributors from a recurring revenue perspective?.

Charlie Goodwin

Well, look, as I mentioned before, Brazil is the second largest cosmetic surgery market in the world, both in terms of procedures, and physicians. The big question is, is that all of them are going to be contributors as we go forward.

The real question is what's happening with the virus in each one of those areas? And so from that perspective, we're basically saying that they're probably not reoccurring revenues until 2021, with respect to just what's happening in the virus in a lot of those different areas.

We did ship as I mentioned, Brazil and Australia in Q2, and we do expect to ship initial order to the remaining three countries during the second half of the year.

But unfortunately different things are happening in each of those markets with respect to the virus and so that that will determine when those really start to kick in and really become recurring revenue on a regular basis..

Matthew O'Brien

Okay, that's helpful. Thank you so much..

Charlie Goodwin

Thank you..

Operator

The next question is from Dave Turkaly of JMP Securities. Please proceed with your question..

Dave Turkaly

Thanks. Charlie, we spoke about - a bit about the doctors and their practices being reopened. So thanks for all that color. Just curious about the actual customers or patients, I'd love to get your current thoughts on sort of their mindset. You know, you mentioned that these are mostly outpatient or office procedures.

But we talked about maybe people having some downtime and being willing to get a procedure done. I'm just curious as to what you're seeing or hearing from, maybe even from the patient base out there.

Are things improving, and I guess do you expect that to hold?.

Charlie Goodwin

Yeah, by all accounts. All our customers in the month of July were busy. In some regards they said it was the busiest July that they've ever seen. As far as do I expect it to hold? I think it's in the early stages right now. And I think it's tough and demand remains uncertain.

And so the - you know, that is why in the remarks that we said, we hope for a quarter-over-quarter growth in the fourth quarter.

We were obviously extremely pleased by July to be able to grow our business 35% year-over-year, but the big question is, is what happens to demand and what happens in the back half of the year and as we sit here today, we're extremely excited and cautiously optimistic about what that looks like going forward. But I don't have the answer to that.

I do know that there was an article just published in Barron's that talked about cosmetic surgery just going crazy right now, but who knows that that lasts? Who knows it's - there's a whole bunch of factors in there and it just remains uncertain..

Dave Turkaly

Got it.

And I don't know if I've asked you this in the past, but for your Advanced Energy specifically, is there a median age that you've talked about in terms of the patient that are seeking therapy there?.

Charlie Goodwin

Well, I don't know if there's a median age, but we've done ages from - our customers have done ages from 20s to 80s. And so, if you're going to probably pick a median age, it probably fits in that 45 to 60 age group is probably the sweet spot for skin tightening, if you will..

Dave Turkaly

Got it. And just quickly, you mentioned the sales team was held steady.

I wondered if maybe care to share any details of that sales force, like the size and either, you know, maybe just even domestically?.

Charlie Goodwin

Yeah, the size hasn't changed from the beginning of the year. We haven't made any – we haven't made any changes in our size.

And I quite honestly don't have the exact number on the top of my head of how many we have, because we haven't changed it and since the end of last year, and I think we're - I don't even want to give you the number, I know we're at 30 some direct people, but I don't know what the exact number is right off the top of my head..

Dave Turkaly

No, it's fine. But thank you for that. And thanks for all the detail..

Charlie Goodwin

You bet. Thank you..

Operator

The next question is from Kyle Bauser of Colliers Securities. Please proceed with your question,.

Kyle Bauser

Hey, Charlie, and Tara, thanks for taking the questions. Maybe I'll start off with the skin laxity trial. So as you mentioned, two phases, first phase is 20 patients evaluated for safety, I think one month follow up. And then you can proceed with the subsequent 32 patients, with all 52 evaluated for efficacy.

Can you just talk about the status of the trial and the first phase of this for that initial 20 patients and kind of where we are?.

Charlie Goodwin

Yeah. So look, we're not going to give specific updates on where we are. But as I mentioned, all the activity was impacted by COVID. But thank goodness that all of our sites are back up and running and we're making progress towards that.

Therefore that study, in particular, the next milestone that we would give out is after we have received approval to begin phase two of that study. That's the next phase of that study. And until then, you know, we're working towards that goal of being able to proceed to the phase two of that study..

Kyle Bauser

Okay, that's helpful. Thanks. And I know capital equipment sales were pretty minimal in Q2, given the shutdown. Practices just aren't putting up the money for capital equipment right now.

But it would, therefore, seem the value proposition that your partner MedShift provides to be pretty compelling right now, since practices can just do a monthly subscription and get access to these.

Does this model maybe seem more interesting right now to customers, since they don't have to buy the capital equipment or is it too early to tell?.

Charlie Goodwin

Yeah, no. Look, it is a very good model, MedShift is - they're very good partner for us. And it is a another way for our customers to adopt that technology. And it's a way that we always have offered that. And so as I mentioned before, we have outright capital purchases, we have leasing programs, we have the MedShift program.

And so we definitely try to make it as easy on the practice and tailor an approach to the practice to have them adopt the capital as, you know, whatever fits best into their business model. And so it's wonderful to have MedShift as a partner for that and yes, it is a good approach.

The biggest thing though, it still has - the customers still have to have confidence that they're going to be able to stay open and you know, get a return on that investment.

And I think that's really still the biggest thing and the reason why there is, why we're cautiously optimistic about the second half is just because of you know, we obviously don't have control of the virus..

Kyle Bauser

Okay, got it. Got it. Well, thanks for taking the questions and appreciate the color on favorable trends in July..

Charlie Goodwin

Thanks, Kyle..

Operator

[Operator Instructions] Our next question comes from Russell Cleveland of Renn Capital. Please proceed with your question..

Russell Cleveland

Hello, Charles.

And a question is on the cash refund, will we be getting actually $3.7 million and that will add to our cash? Or are we already showing that in our cash balances?.

Charlie Goodwin

Yeah, no. Go ahead, Tara..

Tara Semb

Yeah, that's - its approximately 3.7 is an actual refund, because we'll be carrying back the loss to 2018 when we paid income taxes..

Russell Cleveland

So we're going to get $3.7 million more this year, which is of course a big help to us..

Tara Semb

Correct. Okay, question….

Charlie Goodwin

Russell, hold on one second, I'm sorry to interrupt. Not only will we get $3.7 million back this year, but then we'll get depending on what our losses are, for this year we will get another chunk of it back the following year, too..

Russell Cleveland

Okay. So cash drain is not as bad as we think. That's the point..

Charlie Goodwin

Correct..

Russell Cleveland

My other question is, you know, many were surprised that Brazil was the number two cosmetic country, what other countries are, say in the top five or top 10? Do you know, that?.

Charlie Goodwin

Yeah, the two biggest ones that we do not have registration in right now are China and South Korea..

Russell Cleveland

They're in the top five..

Charlie Goodwin

They are. They're both in the top five. And we don't have business in either one of those. Our products aren't registered there yet..

Russell Cleveland

All right.

Are we going after those markets or is it a regulatory problem?.

Charlie Goodwin

No, we have strategies for both of those markets yes,.

Russell Cleveland

All right. Okay, that's all. Thanks so much..

Charlie Goodwin

Thanks, Russell..

Operator

That does conclude our conference for today. Thank you for your participation..

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