Everybody, welcome back. We have now moved on to Integra LifeSciences. We were talking just before the session started how I've been covering Integra LifeSciences the entire time remotely. It's nice to be able to see everybody's face, and I wish I was seeing everybody who's listening to this face also. This is the world that we live in. Anyway, Carrie, let's get started. You became the CFO of Integra, I think in June of 2019, if I'm not.
That's right.
So you've been there about, call it, almost two years. What have you seen? What's been the greatest surprise? And what has been sort of like, "didn't know that when I was coming in"? Wish I had.
Yeah. Well, I would say in terms of positive surprises, part of what attracted me to Integra was its company mission. We have a mission that says we're going to reduce uncertainty for clinicians. And that's a powerful mission statement. The products that we manufacture and deliver really impact and save people's lives. So it's pretty powerful stuff. And we have all-employee meetings once a quarter. And one of the great things about these all-employee meetings is that we bring patients that have been impacted by our products, and they come and provide testimonials to our all-employee meetings. And it's just such a powerful statement to hear their stories. It's really nice to work in the med tech space, specifically for Integra, though some of the products that we manufacture are just incredible. The other thing I would point to is just the overall culture for Integra.
It's a pretty encompassing culture. And you think about it, my tenure, as you mentioned, is coming up in June for two years. About half of that tenure is going to be virtual at this point. And as you think about just the quality and the effort of the people, as you think about during COVID, one of our top priorities was to preserve as many full-time jobs as we could when we started to go through the COVID impact. And just the unification of the team around that and around doing what was necessary to get through COVID was pretty inspirational and says a lot about the culture that Pete and the rest of the leadership team have created. On the negative side, I would say there's nothing that has really surprised me that I didn't expect when I came in.
But I would say, as a CFO, you've got to constantly be prioritizing and allocating spending. There's a lot of mouths to feed. And what I mean by that is not the number of people, but number of projects, number of opportunities that come across my desk in terms of the demands of wanting to spend. And so you've got to make sure that you're balancing both long-term and short-term for the company. And certainly, when you throw in COVID in the mix, that really tests that prioritization because we needed to make pretty hard decisions on what we were going to protect and what we could do without for a little bit of time. A little bit of a high-class problem to have, but certainly one that I've enjoyed over the last couple of years.
How have you seen the strategy shift over that period of time also?
Yeah. I would say other than the interruption of COVID, and unfortunately, we're still living with COVID, we obviously had to shift a little bit in 2022. But other than that, I wouldn't call it a shift in strategy. I would call it the execution of the strategy that we've continued to articulate. If you talk about CSS, the most transformative acquisition we did for the company was in that space with the Codman acquisition. It was really transformative. It brought enormous scale to our neurosurgical business. And the other thing that it brought, in addition to scale, was international presence. And so when you think about what we've been able to do since the Codman integration, Glenn Coleman, our COO, spent a lot of time last week on our earnings call talking about Japan.
If it wasn't for Codman, we wouldn't have the presence that we have to really build such a great business in Japan. He talked about it as, "It's a $60 million business for us, Japan alone." And it is our largest country outside of the U.S. now in terms of revenue. And for the last six quarters, it's been a double-digit grower for us even during COVID. So pretty impressive in terms of execution of our strategy. And then on the TT side, well, obviously, Ortho was a big piece of our portfolio shift there. But now just talking to the TT side, we don't have scale yet in the tissue technology business. So while we've got it in CSS, we still have the opportunity to add more scale into the tissue technology business. ACell allows some of that.
We've kind of doubled down in the regenerative tissue side, but we still have the opportunity to add more scale to TT, and it's really about thinking about treating the most complex tissue defects that are out there and understanding that in order to do that, you have to bring multiple technologies to bear to clinicians.
That's a lot to get started on. But I do want to spend some time talking about the pandemic because one of the things that has really become obvious to me, at least when we look at Integra, is the capital percentage of the business versus the procedural percentage of the business. And then obviously, you overlay on that Codman and then TT. And so how do you think about what's working today and then what's going to work on the other side of the pandemic?
Yeah. Well, as you think about the pandemic, certainly we saw really deep lows when it first started. Our business in the second quarter was down 30%. Saw some really nice recovery at the end of the second quarter into the third quarter and a little bit of a plateau into the fourth quarter. But there were parts of our business in the third quarter and the fourth quarter that reached back into growth territory. So as you think about parts of our neurosurgical business, CSF management, dural access and repair, and neuromonitoring all got back to growth into the fourth quarter. So as we think about procedures and the deferability of those procedures, it was really nice to see that things that we ultimately didn't think were going to be that deferable come back to us in the fourth quarter into a growth territory.
Even parts of our tissue technology business in the regenerative side of the business in the inpatient area also returned to growth. It's nice to see some elasticity in coming back as hospitals recover and are getting used to more of coexisting with COVID. You mentioned capital. Capital is still a laggard in our recovery. Very early on when COVID hit, we anticipated. We said publicly that we thought COVID would be most impactful to the capital side of our business. It would be the area of our business that would be one of the slowest to recover. Unfortunately, it has played out that way. While we saw some nice sequential recovery from the third quarter into the fourth quarter on capital, where the total company was only down 1.5% in the fourth quarter, capital was still down 18% in the fourth quarter.
Our view is that it's going to continue to lag the recovery as we go through 2021.
We've been hearing different things about capital. Some which are saying hospitals had extra budget at the end of the year and they saw a strong fourth quarter. Some saying that hospitals are purchasing capital in anticipation of procedures recovering. Are they talking different types of capital, or did you see that also and still down 18%?
Yeah. I would say we did see that. So typically, the fourth quarter is our biggest capital quarter, exactly for the reasons you talk about, that typically that you're at the end of the year, hospitals have some budget money to spend. Everybody's rushing around to spend the remaining budget, so they don't get it taken away from them the next year. So there is a normal buildup of capital sales that happens in the fourth quarter naturally. I would say that was part of the sequential improvement from the third to the fourth quarter. But I would say we certainly didn't see the normal really high increase in capital that we would normally see. And as a result, our capital was still down 14%. But we saw the same general trends, just not to the peak level that we would have expected.
And so I think some of that happened. Some of it is still being constrained because of the uncertainty as November and December were still quite large in terms of surges of COVID that continued in January. And so I really think that our view of the world is that it's still going to lag, and we probably won't see real recovery until the second half of 2021. And it's mainly due to it's not around ICU bed availability. It's not tied to that. It's more tied to CFOs like me at hospitals basically saying, "When am I going to turn the faucet back on? When do I have certainty that any potential surges or the impact of any variants aren't going to dramatically change my financial outlook for the hospital?
And so when you think about procedures recovering, and we've been talking to people about this all day, the vaccine is being rolled out. We're entering the summer months. Is this a classic case of second half for Integra's going to be stronger than the first half? Or how do you think about that?
Well, gosh, I hope so. And I hope we're into a part of the year in the second half where we're not talking about COVID anymore. And so as we looked at our guidance, and Joanne, it's one of these things we had to make a decision, do we guide or not guide? There was a little bit of mixed bag of companies that did provide guidance and companies that didn't provide guidance. I think for us, not that we have any great crystal ball that says we know when COVID's not going to be around us anymore, but it was more for the fact we gave guidance because we had a lot of change in our portfolio with the divestiture of Ortho, ACell coming in. And frankly, we still saw a COVID overhang in Q1.
And so we needed to recalibrate, reset expectations because I think a lot of analyst models were not yet calibrated, and we're looking for guidance. So we thought the best thing to do was provide at least some level of guidance and to give you at least a roadmap of how we were thinking about it. So we chose our words pretty carefully around our guidance for the full year. We talked about a slow, gradual first-half recovery, which implies that gradual recovery was tied to the first half, which implies that the second half, we're not anticipating any COVID impact in the second half, and we can get back to more normalized growth levels. So I think that's the way we framed it. Now, we're going to know a lot more in April than we know now as part of our Q1 call.
And so hopefully, we'll be in a better position, certainly to give you the results of Q1, give you some guidance around Q2, which will help you shape your first half, second half expectations a little bit better in April than what we're giving you now. And certainly, if we know more positive or negative, that may change overall our guidance range. But this was the best information we could provide at the time.
And stepping in a different direction, one of the things that has always struck me as Integra has been constantly moving in terms of portfolio management. And even just in the last two years, the acquisitions of Rebound Therapeutics, Arkis Biosciences, obviously ACell, the exit from Extremities. Can you help me understand holistically how does management think about building a portfolio?
Yeah. And I think we've been pretty consistent here. I mean, part of our goal is to simplify the portfolio. And I think through the actions that we've done, we've certainly done that. But I would say the prevailing strategy is to build scale and leading market positions in the markets we do play in. So let's start with CSS. I mentioned that the Codman acquisition is the most transformative acquisition in the company's history. We were already on the map in neurosurgery, but this basically brought us to the number one spot with the J&J acquisition of the Codman business there. And we talked about the international presence that it brought specifically in Japan, as well as China, is now really strong growth platforms for us.
So you take that strategy, which really started to formulate with the Codman acquisition, and now you go through a couple of years here through the integration of Codman. And then we were in a position to think about what's the next stage of the evolution of CSS? Well, it's about we already have the scale, so now it's about innovation and growth. And so we then looked for acquisitions that really were an extension of our R&D pipeline, looking for a couple of transactions. Arkis and Rebound were pre-revenue, but really brought some innovative technology to bear to the portfolio. Now, these are still pre-revenue. I would say of the two, Arkis and Rebound, Rebound is going to be the most potentially disruptive technology for it. It has the opportunity to really transform neurosurgery in a couple of areas.
Number one, in the area of minimally invasive approaches to neurosurgery. So think of the traditional neurosurgical approach when you're resecting a tumor. You do an open craniotomy. You've got to open the brain up in a pretty large way and complicated way to get access to the brain. The Rebound product is called Aurora. So you're going to hear us talk about the Aurora Surgiscope quite a bit. You get access to the brain through a burr hole, and you bring the Surgiscope, which is a trocar device that allows you to bring tools into that narrow channel and get access to the brain through a burr hole rather than an open craniotomy and be able to get access to these tumors in a minimally invasive way. And what's so novel about this is that it's completely disposable. The Surgiscope is disposable.
It has its own visualization, its own lighting source, its own camera right on the device, and it's completely disposable. And it plugs into the monitors that are already existing in the operating theater. So no additional capital that's required from the hospital. So it's pretty novel and pretty disruptive when you think about changing how neurosurgeons access brain tumors. The second shot on goal with this technology is equally disruptive in that it allows us to do a surgical approach to deep bleeds, the ICH market, the intracerebral hemorrhage market for strokes. There really isn't any surgical approach right now. It's mainly medical intervention, and it's really just medical intervention to alleviate the discomfort of the patient and to prevent any other complications of the patient.
What this allows you to do is basically get access to the brain and be able to get the blood off of the brain quickly in order to have much more positive outcomes for the patient. So for us to have the scale in neuro and then have the possibility to do an acquisition like we did with Rebound that really can be transformative in and of itself through innovation is really part of our strategy. So that's kind of the CSS piece. And then so you talk about let's now shift to the TT piece, the ortho divestiture. So let's talk about why we did the ortho divestiture. The end markets that the orthopedics play in are actually attractive end markets. Those are fast-growing markets. But it wasn't the case for Integra. These were markets that unfortunately we weren't able to have any substantial growth.
For many years, we had negative growth, and we took the business as far as we could. We got the business basically to be neutral from a growth perspective. So it was basically flat. And we had a couple of really great products in the ankle area and the shoulder area. And so we got the business as far as we could. And ultimately, to get it to any chance of growing at the market rates, it was going to take substantial investment. And as we looked at our choices of where to spend those investment dollars, ultimately, we came to the decision that we could spend those investment dollars more appropriately and have better outcomes if we rotated those investments to either neuro or our regenerative tissue space. And that's the decision we came to.
Ultimately, we think it's in better hands with Smith & Nephew, that we think they'll take it to the next level that we couldn't. I think that's a little bit of this wish to have scale and relevant presence in our markets and realizing that in ortho we just couldn't get there and made the decision to divest. It's just so lucky that the ACell acquisition came along. You don't get to normally pick your timing of your acquisition so perfectly here. We had the divestiture of Ortho. Then essentially a month and a half later, we announced the acquisition of ACell and basically closed both of those transactions in the month of January. It worked out well. With ACell, that allows us to bring scale. I still think we have more opportunity in the regenerative space to continue to add scale.
But what we like about ACell is it aligns very much with our sweet spot. We have a lot of strength in the inpatient channel within the tissue defect wound reconstruction area. And this is in the same call point as our business is. And it also brings another leg to our technology, porcine. We have bovine and we have amniotics, but it allows us to bring another technology leg to the table here. So really excited about what ACell can bring to the table.
You mentioned, I think at least twice now, that there's more opportunity in the regenerative space. What does that mean? Is there a specific area where, "Oh, we really could use this?
Yeah. I think certainly the end markets are pretty attractive, and we did talk about on our earnings call last week that we're going to have a May investor day. May 20th is our investor day. We haven't had one since December of 2017, so we're long overdue for one. And a lot has happened, as you mentioned, in the portfolio, and so we're really going to spend a lot of time talking about our end markets and getting folks comfortable with our end markets and their growth rates and why we think we can grow at those market rates or in some cases exceed the market rate and grow faster than the market, but in terms of some of the complex wounds, these are attractive spaces, and we think they are going to be growing healthy in high single digits.
And we think we can be growing at that high single digit rate. The challenge for these types of markets, the tissue regeneration markets, is that one solution doesn't fit all types of tissue defects. And so what is important is that you have a depth of your toolkit that you can bring to clinicians as they will pick and choose different technologies in the regenerative space to address different complex wounds. And so for us, having that full breadth and having that scale is very relevant in the inpatient wound area, especially as we think about contracting as more and more of the business moves to large contracts where you want to be the player that gets the large contract and has the scale and the depth of portfolio. It becomes very relevant to have a large breadth of products to be able to deliver to.
When you think about building out these products, how do I word this? What is the competitive landscape that you might be coming up against? Because I think sometimes, at least when we speak with investors, it's less obvious who the competitors are for each of your two segments.
Yeah. And I think there are a lot of subsegments within the wound reconstruction space. So there are some companies that specialize in the burn area. There's some companies that specialize more in the outpatient area. That's where a lot of the amniotics come into play. And so certainly, we play in burn. We play in the amniotic space on the outpatient side. But where our sweet spot is and where our heavy concentration is, is in the inpatient side. And I think we have probably the broadest portfolio that we can bring to bear. But there's a lot of places that are more niche. And I think that our opportunity is really in the outpatient. And then to think about a lot of ours are around the dermal repair.
I think future opportunities will be in looking at a combination of full skin graft types of repair, looking at epidermis as well as dermis type of repair opportunities to expand our addressable market. So I do think it's highly segmented. But I do want you to think of Integra as a player that basically kind of goes a little bit end to end when it thinks a lot about its technologies. I think we'll be in a position to drive more innovation to expand our addressable market base.
So given all of these moves in the last 18 to 24 months, does the company take a pause now? Or how do you think about that?
Yeah. Well, I'll first start with that question talking about our balance sheet because I think it's important to understand the balance sheet before you can say whether or not we're going to go on another acquisition spree or not. I am really comfortable with the balance sheet is. And as I think about weathering COVID, I think we did all the right things that we needed to do to weather the storm. And we ended the year actually quite strong. I talked about it on our fourth quarter earnings call last week that our cash balance is $470 million. Our leverage ratio is 3.0 x. We talk about a target leverage window of between 2.5 and 3.5. That's generally where we like to operate in. And I'm smack right in the middle of that at the end of the year.
Now, the transactions we talked about with Ortho divestiture and getting the proceeds from that and then doing the $300 million acquisition for ACell, all of that took place in January. So as I think about my leverage ratio from Q4 into Q1, I don't see a lot of changes in that. I do think we'll still be in the neighborhood of 3.0 x. So I still think we've got a really healthy balance sheet that still allows us to be very opportunistic when it comes to acquisitions. I think Integra has proved that we are a good acquirer of companies. We know how to integrate. Obviously, ACell is one we're busy integrating. And we can talk a little bit about the priorities of ACell in a moment. But generally, I do think that we're still going to be active in the M&A space.
We can't always predict when those things are going to happen. But as I look at CSS, the opportunities in CSS, it's not about scale necessarily in CSS because we have that already. It's going to be around innovation and things that help us grow faster. In the TT side of the business, it's a combination of scale and bringing more innovation to bear in whatever acquisitions we might want to be looking at there. But I do think that it's going to be an important piece. And I do think we have the balance sheet to continue to be acquisitive.
And so you sort of opened the door for my next question, which is integration. And how do you think about bringing not just products together, but sales force and culture so that you don't lose momentum?
Yeah. For ACell, it's a very attractive business for us. And I mentioned to you, not only because of the top line and that it should grow very nicely in our portfolio. So certainly from that perspective, it's very accretive to our organic growth targets of 5%-7%. So it kind of checks the box there. The thing that ultimately makes this a really nice acquisition for us is the financial returns that we think we can generate with this acquisition. Gross margins are very healthy, very much like the rest of the tissue tech business, higher than the average corporate margin. So very accretive as we think about gross margins coming into the fold. But then you look at the opportunities to synergize here.
I mentioned before that ACell is right on the same call points that we have with our tissue technology business that we already have, our legacy business. It's right smack in the middle of our inpatient sweet spot. That's where the opportunities are going to be combined with the opportunity to leverage our infrastructure that we already have. When you look at ACell, they had gone down a path of potentially going through an IPO route. Ultimately, that didn't work out for them. We had the opportunity to acquire them. Some of their financials are public. You can take a look at their financials. As a standalone company, they were not making money. They were essentially break-even. It's not because their gross margins weren't really healthy.
It's because they had an awful lot of sales folks running around, a lot of infrastructure there that we can take advantage of and bringing it into the fold. And that's the synergy realization that we're working on. So as I think about the integration priorities, number one is to minimize any disruption to the top line. There's no doubt that there will be some disruption to the top line. And it's because of the fact that most of the synergies are going to come from the sales channel. When you think about, again, those overlaps on the sales channel, that's where we got to go after the synergy opportunity.
And so the challenge for us is to focus on that first and foremost, get all of the ACell reps that we want to keep conveyed over, which we've done that already, get our territory squared away, get our comp plans squared away, our sales quotas all down. All that's been done. Our focus in early February into February now is about training. We had a national training meeting earlier in the month that we utilized training the new ACell reps on the Integra portfolio, but also now training our own Integra reps on the ACell portfolio. So a lot of the heavy lift has now been done. We've now got to focus on differentiating our products, making sure our sales reps know how to position the ACell products versus the Integra products. There's some overlap, but very little overlap.
There's a lot of exciting things that the ACell portfolio brings to us that we didn't have already, which we're really excited about. We've got to do some work on the ERP implementation, get their order-to-cash process integrated with ours, so still some work to do, and that's where the synergy play is going to be as we realize to get to run rate synergies by the fourth quarter of this year.
So the expense synergies should start second half and revenue synergies second half also? Or I just want to make sure I have my timing here.
Yeah. I would say on the expense side, and I mentioned this on the call, that we get a little bit of benefit just because of the timing on our operating expense in the first quarter. So Ortho comes out for three whole months. We divested Ortho on January 4. So effectively, Ortho is out of the portfolio for the entire quarter. ACell comes in for two of those three months. So you get a little benefit of a heavy burdened OpEx business coming out, ACell coming in, but only for a partial of the quarter. So I get a little bit of timing benefit of that. In the second quarter, you'll see the full burden of ACell OpEx coming in. But we'll start to realize synergies very quickly there as, again, we didn't convey over all of the ACell reps.
So again, my expectation is we'll start to see savings realization in the second quarter, more in the third quarter, and be run rate by the time we get to the end of the year. 2022 will certainly benefit from a full year of seeing those synergies there. On a revenue perspective, what we guided to, and I think if any area of guidance that got poked, it was probably ACell. Some of the view was that it was conservative. I hope that it's conservative. I really do. What we did was we looked at, okay, ACell, what did they generate in revenue in 2020? It was $95 million. We owned them for about 11/12 of the year. So 11/12 of $95 million is about $87 million. We gave a guidance range of $83 million -$88 million.
It certainly brackets that $87 million, but $83 million-$88 million. Acknowledging the fact that where most of the synergies are going to come from is on the sales channel. There could be some disruption on the top line. Our goal is to minimize that as much as possible. Part of our guidance was, give us some time, give us some time to stabilize the business. Most of that impact, we gave guidance for Q1 of ACell being in $14 million-$15 million range. Most of that impact is going to be there in Q1. Hopefully, we'll get to better run rates in the second and the third and the fourth quarter.
There's so much going on. One of the things that's been interesting is to start to listen to the company talking about product launches. And if you were going to rank your favorite two or three or top two or three, maybe better worded, what would they be?
Yeah. I think for near term, I'll answer that near term and a little bit longer term. The near-term opportunity in 2021 is the launch of our CereLink intracranial pressure hemorrhage or sorry, intracranial pressure monitoring system. That will be a second-half launch. And we think the timing of that launch is great. We do think that, again, most of COVID will be behind us, a good time to launch a new capital piece of equipment. You're probably talking about in the range of $30,000-$40,000 in terms of an average selling price of that unit. This is an end market we know very well. We have experience with ICP monitoring back even before Codman. And this is a business that really has been sorely lacking any technology advancements. So our CereLink product, we think, is going to be really well received.
It brings a better user interface to it. It brings new data analytics to bear. And so we think this is a technology that is ripe for launch at this point where there just really hasn't been any technology innovation. When we did the Codman acquisition, we had our own ICP monitor that because of FTC reasons, we had to divest of our legacy product. And we made the decision to keep the opportunity to launch the CereLink product. That business, when we divested it, our legacy ICP was called the Camino. When we divested that, that was a $30 million revenue stream for us. So my expectations for the CereLink, certainly we won't reach $30 million in 2021. But my expectation is that there's no reason that that product, the new CereLink product, shouldn't get us back to a $30 million revenue line for ICP or even more.
I'd be disappointed if we couldn't even get more because I think it's a better technology type of solution. Longer term, I would go back to the Rebound Aurora Surgiscope opportunity that we talked about. Really disruptive opportunities in two spaces we talked about, in minimally invasive neurosurgery approach as well as the deep bleed, the ICH stroke market. And again, you won't see much impact in 2021. And we're going to do limited release of the Aurora Surgiscope with KOLs to continue to build adoption and clinical evidence in those things. But I would say that you'll start to see a larger contribution in 2022 and certainly in 2023. And if there ever was a home run for us, this is where I'd place my bet is on the Aurora Surgiscope opportunity for us.
And then the last area of what I call another home run opportunity for us is in the world of surgical reconstruction. It has to do with our SurgiMend product. The SurgiMend product is used for breast reconstruction surgery. It does not have an indication for breast reconstruction. But there are surgeons that are using it for that. We are right now working on building clinical evidence to support an indication for breast reconstruction in the U.S. for SurgiMend. We think if we can get that, that will unlock some huge growth potential in that product. Now, that's probably a couple of years away. But again, as I think about home runs for us, that's another one where we think we have a really innovative technology. And we just need now the clinical support that allows us to really be able to sell it and advertise it for breast reconstruction.
So I would anticipate when you get to the May analyst meeting that you'll update the LRP. Is that an accurate anticipation?
Yeah. And I wouldn't expect any surprises, Joanne, on that. One of the things we've been doing is Pete was at a conference earlier in the year in January on Glenn's remarks during our fourth quarter call. We had the exact same side that Pete did, which is re-emphasizing and reiterating our long-term plan objectives: 5%-7% organic growth, adjusted gross margins of 70%-72%, adjusted EBITDA margins of 28%-30%. We are not walking away from those. Those are absolutely achievable. And the things that we've done with the portfolio in 2020 and obviously the most recent things we've done with ortho and ACell give us even greater confidence of our ability to hit those long-term plans. What we need to calibrate is on the timeline of when we can achieve that. Obviously, COVID did impact our revenue line.
Part of our ability to achieve some of those margin goals relates to having the revenue there. I think, though, we have demonstrated, hopefully, it's pretty evident in 2020 that even when revenue was down, we actually continued to expand our margins. Revenue was down 10% in 2020, yet we expanded our gross margins by 50 basis points in 2020 and actually edged out a little bit of margin expansion on the EBITDA line as well, so we think you put a little bit of revenue back in. If you can get to a world that's post-COVID, and hopefully, we can all think about that, then I think that this business scales quite wonderfully, and it's no stretch to be able to think about getting to those margins once revenue gets back into a healthy growth pattern of 5%-7%.
Now, some of the expansion is at least obvious to me, which is new products, higher margin products, getting rid of lower margin products. But there's, I'm sure, things that are less obvious to me. What is going on behind the scenes that you can share that helps move you towards that better margin?
Yeah, well, a couple of things. Discontinued product is a big piece of it, and I'd point to that as one of the drivers that allowed us to expand our gross margins in 2020, even though revenue was down. We've talked about this, that sometimes we get a little bit of flak for taking the impact of discontinued products out of our organic growth, so when we do report it to organic, that is one of the adjustments that we made. For us, we look at it as value-creating mechanisms. Look, if we could have sold those products and sold it to a strategic buyer or financial buyer, we would have done that, but some of these products that we made the decision to get out of just are commodity-type products. A lot of them we inherited when we did the acquisition of Codman.
And so as we integrated the Codman acquisition, we took a sharp focus on the portfolio of looking at what we wanted and what we didn't want. It does take some time when you don't divest of a product and you discontinue a product. It takes some time to wean it out of your revenue line. And that's what's happening. We talk about that 2021 should be the last significant year of product discontinuation for us. But there's no doubt in my mind that it has created value for us by making these changes, by staying committed to the SKU rationalization program, simplifying our portfolio because these products were slower growers. But more importantly, they were below the average gross margin of the company.
As we get rid of those products, as they come out of my revenue line, they change my gross margin mix to a healthier mix. The other thing that is going to be a lever for gross margin is the overall growth of tissue technology. Both CSS margins are very healthy and tissue technology margins are healthy. But tissue technology is greater margins than CSS. So as we worked to address bottlenecks of capacity in 2019 and as we add in ACell, which brings even more tissue technology to bear in our portfolio mix, all of that has a positive impact on my overall gross margin mix as well. The other piece that helps us into 2021 and into 2022 is related to the last final piece of the Codman acquisition, is getting off of the TMA agreement with J&J.
They still manufacture some of our products in the CSS portfolio. We have set up our own facility in Massachusetts that is about 25 miles away from their facility. We have conveyed the J&J employees over to that new facility, and we will start to transition products over the course of 2021, and our expectation is we will be 100% off of that TMA agreement by the end of 2021. It's a gradual phasing out, but every time I move a product over, I get off of that agreement, so it's not a cliff. It's basically a gradual improvement of gross margins as I go through the year, as I get off of that TMA agreement, and then 2020 will have the full benefit of us off that agreement 100%.
All good stuff. One of the things we didn't talk about was your manufacturing. And you sort of started to go in that direction. But you've increased manufacturing capabilities at the Memphis and the Boston plants. What did you get out of that?
Yeah. Well, that goes back to part of the missteps that we had. Again, part of our issues in 2019 was that we did not meet expectations of growth in our tissue technology business. We surpassed them in our CSS business. And that helped offset and land us in 2019 in a reasonable place. But where we missed was on the tissue technology side, specifically in two facilities, Boston and Memphis. Boston makes our SurgiMend and PriMatrix products. And the Memphis facility makes our amniotic products. So the capacity was to address some of the key bottlenecks in those facilities. And we largely were in a really good spot at the beginning of 2020 and saw some really nice growth at the beginning of the year. And then COVID hit. But what we did in 2020 was in some of our other facilities, we actually took shifts out.
We took hours out, but in Memphis and in Boston, we kept building, and that was because we weren't at an inventory level that we were comfortable with. We wanted to get our safety stock levels to a reasonable place, and if anything came out of COVID that was good, it allowed us to get our safety stocks back together so that when the recovery does happen and we started to see the recovery in the third and the fourth quarter in the tissue tech business, it allowed us to be able to meet the demand that we couldn't before.
So in the few minutes remaining, I want to ask you my favorite question, which is, what do you think investors are missing right now?
You know, I think for us, there's a lot of things that have happened. And I hope that for them that everything is clicking now. For me, I think it's about having greater confidence now in our long-range plan. There's been a lot of doubt of whether this company could grow in the 5%-7% organic growth range. I hope that with the portfolio actions that we have just done with a slower-growing business, a $100 million business coming out that basically wasn't growing, swapping that in with a $100 million business that will grow very nicely for us convinces the investor that we have confidence in the 5%-7%. It certainly has convinced me. It certainly has given me greater confidence in the 5%-7% and why we're not walking away from the 5%-7%.
And I think that the investment thesis I would leave you with is we have really nice, attractive end markets. We're going to spend some time on May 20th going through those end markets with you, hopefully to convince you that they're attractive spaces to participate in. We have market-leading positions in those spaces. And we're bringing constant innovation around those. We talked a little bit about some of those opportunities on the innovation space with the Arkis and the Rebound acquisitions as well as some of the work we're doing on breast and even some of the work that we're doing on the nerve side of the business. So we think good end markets, leading market positions, really nice innovation pipeline.
And all of that leads to some really nice opportunities to expand margins and ultimately drive earnings growth and cash flow that allows us to continue to reinvest and continue our M&A history of being acquisitive companies. So I think all of that is, I think it's all coming together. A lot of important decisions were made and actions taken here at the end of the year into January that positioned us really, really well.
Carrie and Mike, we have covered so much ground in 45 minutes.
Yes, you did.
Thank you. Thank you, both of you. And I look forward to May and to talking to you again soon.
Very nice to see you, Joanne. Thank you.
Have a great day.
Thanks, Joanne.
Okay.
Have a nice day.
Bye-bye.