Kinetic Concepts, Inc. v. Smith & Nephew, Inc.
Justia.com Opinion Summary: Wake Forest is the owner of asserted patents, and KCI are the exclusive licensees of the patents, which claim methods and apparatuses for treating difficult-to-heal wounds by applying suction or negative pressure. In response to S&Nβs 2008 announcement that it was launching a new foam-based negative pressure wound treatment product, Wake Forest and KCI asserted that S&N infringes two apparatus claims of the patent and induces infringement of four method claims. Rejecting the juryβs findings of non-obviousness, the district court found obviousness, based on prior art, and rejected infringement claims. The Federal Circuit reversed and remanded. The objective evidence strongly supported the juryβs findings under the first three Graham factors and cut against the view that the claimed inventions were an obvious combination of known elements from the prior art.
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United States Court of Appeals for the Federal Circuit __________________________ KINETIC CONCEPTS, INC., KCI LICENSING, INC., KCI USA, INC., KCI MEDICAL RESOURCES, KCI MANUFACTURING, AND MEDICAL HOLDINGS LIMITED, Plaintiffs, AND WAKE FOREST UNIVERSITY HEALTH SCIENCES, Plaintiff-Appellant, v. SMITH & NEPHEW, INC., Defendant-Appellee. __________________________ 2011-1105 __________________________ Appeal from the United States District Court for the Western District of Texas in case no. 08-CV-0102, Judge W. Royal Furgeson, Jr. _________________________ Decided: August 13, 2012 _________________________ MATTHEW D. POWERS, Weil, Gotshal & Manges LLP, of Redwood Shores, California, argued for plaintiffappellant. With him on the brief were ELIZABETH STOTLAND WEISWASSER, PETER SANDEL, JENNIFER H. WU, KINETIC CONCEPTS v. SMITH & NEPHEW 2 DANIELLE ROSENTHAL and ERIN WIGGINS, of New York, New York. Of counsel was ANDREW SWANSON BROWN. JOSEPH R. RE, Knobbe, Martens, Olson & Bear, LLP, of Irvine, California, argued for defendant-appellee. With him on the brief were JAMES F. LESNIAK, SHELIA N. SWAROOP and CHRISTY G. LEA. Of counsel on the brief was MARK J. GORMAN, Smith & Nephew, Inc., of Cordova, Tennessee. __________________________ Before BRYSON, DYK and OâMALLEY, Circuit Judges. Opinion for the court filed by Circuit Judge OâMalley. Circuit Judge Dyk concurs in the result. OâMALLEY, Circuit Judge. Wake Forest University Health Sciences (âWake Forestâ) appeals the district courtâs grant of judgment as a matter of law (âJMOLâ) of invalidity for obviousness. In granting Smith & Nephew, Inc.âs (âS&Nâ) motion for JMOL, the district court overturned the juryâs determination that S&N had failed to prove that the asserted claims of the patents in suit were obvious. We conclude that, on the basis of the juryâs factual findings, S&N failed to establish by clear and convincing evidence that the claims were obvious. Accordingly, we reverse and remand.1 The concurrence raises, and then purports to resolve, issues that were neither raised nor discussed before the district court, and were not argued in this appeal. Because it is about matters not before us, we do not respond to the concurrence except to the extent our discussions of the patents and the prior art already do so. 1 3 KINETIC CONCEPTS v. SMITH & NEPHEW BACKGROUND I. Asserted Patents Kinetic Concepts, Inc., KCI Licensing, Inc., KCI USA, Inc., KCI Medical Resources, KCI Manufacturing, and Medical Holdings Limited (collectively âKCIâ) and Wake Forest brought suit against S&N, alleging infringement of U.S. Patent Nos. 7,216,651 (ââ651 patentâ) and 5,645,081 (ââ081 patentâ). Wake Forest is the owner of the asserted patents, and KCI are the exclusive licensees of the patents. Both patents claim methods and apparatuses for treating difficult-to-heal wounds by applying suction or negative pressure, e.g., â651 patent Abstract; â081 patent Abstract. Wake Forest and KCI asserted that S&N infringes apparatus claims 2 and 5 of the â081 patent and induces infringement of method claims 42, 109, 116, and 121 of the â651 patent. As described by the asserted patents, medical âtreatment of open wounds that are too large to spontaneously closeâ is difficult. â081 patent col.1 ll.11â12; â651 patent col.1 ll.29â30. âWound closure requires that epithelial and subcutaneous tissue migrate from the wound border toward the wound.â â081 patent col.2 ll.49â50. To facilitate such migration, doctors commonly use mechanical closures, such as sutures or staples. Id. at col.1 ll.24â25. Such mechanical closures create tension on the skin, which encourages epithelial migration. Id. at col.1 ll.25â 28. âWhile suturing and stapling of wounds is widely practiced, it has a major drawback: the tensile force required to achieve closure with sutures or staples causes very high localized stresses at the suture insertion points, resulting in the rupture of the tissue at these points.â Id. at col.1 ll.28â33. This rupturing inhibits healing of the wound. Id. at col.1 ll.33â35. Additionally, it is not feasi- KINETIC CONCEPTS v. SMITH & NEPHEW 4 ble to suture some large open wounds. Id. at col.1 ll.28â 33. To address these shortcomings, the invention applies ânegative pressure to a wound over an area sufficient to promote migration of epithelial and subcutaneous tissue toward the wound, with the negative pressure being maintained for a time sufficient to facilitate closure of the wound.â Id. at col.2 ll.45â49; â651 patent col.4 ll.18â23 (â[A] method of treating tissue damage is provided which comprises applying a negative or reduced pressure to a wound over an area sufficient to promote the migration of epithelial and subcutaneous tissue toward the wound and for a time period sufficient to facilitate closure of the wound.â). Claim 2 of the â081 patent and claim 42 of the â651 patent are illustrative: 2. An apparatus for facilitating the healing of wounds, comprising: vacuum means for creating a negative pressure between about 0.1 and 0.99 atmospheres on the area of skin including and surrounding the wound; sealing means operatively associated with said vacuum means for maintaining said negative pressure on said wound by contacting the skin surrounding said wound; and open-cell polymer for positioning at the wound within the sealing means for preventing the overgrowth of tissue in the wound. â081 patent col.9 ll.50â65. 42. A method of treating a wound comprising the steps of: i. providing a vacuum source capable of providing at least 0.11 atm of reduced pressure; 5 KINETIC CONCEPTS v. SMITH & NEPHEW ii. locating a flexible adhesive cover over the wound, said cover having a suction port; iii. locating a porous material comprising a synthetic polymer under said cover at the wound; iv. adhesively sealing and adhering the periphery of said cover to tissue surrounding the wound to form a continuous seal; v. operably connecting said suction port with said vacuum system for producing said reduced pressure; vi. interposing a fluid trap between said suction port and said vacuum source; and vii. maintaining reduced pressure of at least 0.11 atm at the wound until the wound had progressed toward a selected stage of healing. â651 patent col.25 ll.31â48. KINETIC CONCEPTS v. SMITH & NEPHEW 6 Figure 1 of the â651 patent discloses the key components of the claimed apparatus: As depicted in this figure, the claimed apparatus includes: (1) a vacuum pump (30) ; (2) tubing (12); (3) an opencelled foam wound screen (10); and (4) an adhesive seal (18). â651 patent col.6 ll.31â61; see also â081 patent col.2 ll.30â35 (âFlG. 1 shows a cross-sectional view of a negative pressure device comprising a open-cell polymer screen, a flexible hose connecting the foam section to a suction pump, and a flexible polymer sheet overlying the foam-hose assembly to provide the necessary seal.â). To utilize the apparatus, â[f]irst, the open cell foam is cut to fit the shape of the wound and placed inside the wound. Then the adhesive seal is placed over the foam that is 7 KINETIC CONCEPTS v. SMITH & NEPHEW inside the wound.â Kinetic Concepts, Inc. v. Blue Sky Med. Grp., Inc., No. 08-cv-102, slip op. at 2 (W.D. Tex. Oct. 10, 2010) (order granting defendantâs motion for judgment as a matter of law of invalidity for obviousness) (ECF No. 605) (âJMOL Orderâ). Once the seal is in place, â[o]ne end of the tubing is placed through the seal into the foam and the other end is attached to the vacuum pump. The vacuum pump is turned on and, because of the tight seal around the wound, the edges of the wound immediately begin to move together.â Id. II. Prior Art In the present litigation, S&N asserted prior art that generally falls into three primary categories: (1) the Bagautdinov references; (2) the Zamierowski reference; and (3) the Chariker-Jeter references. On appeal, there is no dispute that these references are all prior art. A. Bagautdinov References The Bagautdinov references consist of two articles written by Dr. Bagautdinov. The first reference (âBagautdinov Iâ) was published in 1986. Joint Appendix (âJ.A.â) 10001â03. It discusses âa method for vacuum treatment of primary and secondary purulent wounds.â J.A. 10002. The reference describes the method as follows: After surgical treatment of the purulent wound and hemostasis, a drain of polyurethane foam adapted in shape and size is placed on the surface (or in the cavity). The surrounding skin is smeared with sterile vaseline, antiseptic or inert salve on an oil base and covered with a polyethylene film. . . . Regardless of the method of sealing, a tube is hermetically installed onto the foam through a hole in the polyethylene made before- KINETIC CONCEPTS v. SMITH & NEPHEW 8 hand. The latter is connected to the vacuum pump through a collection vessel. At a vacuum of 10 to 60 mmHg the film clenches the wound strictly along its skin boundaries with uniform vacuum treatment of the walls only on the side of the cavity and elimination of exudate because of the porous structure of the drain. The duration of the treatment sessions depends on the degree of vacuum and ranges from 30 minutes to 2 hours, whereupon the polyethylene is removed and a gauze bandage emplaced. The sessions are conducted daily until the wound is clean. On average this procedure takes 3 to 4 days. Id. Bagautdinov I notes that use of this method âinevitably obtain[s] acceleration of the healing periods and rehabilitation of the patients.â J.A. 10003. The second reference (âBagautdinov IIâ) was also published in 1986. J.A. 10026â27. Bagautdinov II describes application of a method similar to that described in Bagautdinov I to 170 patients. J.A. 10026. The method employed requires that, [i]mmediately after surgical treatment of the infected area in the commonly accepted manner or using a Scalpel-1 laser, a drain made from polyurethane foam is placed in the wound. For sorption treatment, it is first filled with activated charcoal powder. The wound is sealed with polyethylene film in one of several ways, depending on the localization of the purulent focus. Vacuum aspiration is conducted through an aspiration tube using a constant suction pump. Thus, the polyethylene film âclenchesâ the wound strictly along its edges, and the sorbent makes secure contact with the walls. The porous structure of the drain allows for removal of exudate and vacuumi- 9 KINETIC CONCEPTS v. SMITH & NEPHEW zation of the wound only from the cavity side. The session lasts 1-2 hours with negative pressure of 10-40 mmHg, after which the isolation is removed. The drain is changed 1-2 times daily. Vacuum treatment was continued for 3-4 days. J.A. 10026â27. As a result of this method, â[o]n average, the wound became clean by day 4-5, with the appearance of granulated tissue. . . . The average duration of inpatient treatment was 11.8 bed days, compared to 17.2 in the control group; 61.7% of the patients were released with healed wounds and did not require outpatient treatment.â J.A. 10027. B. Zamierowski Reference The Zamierowski reference is a Patent Cooperation Treaty Application filed on April 3, 1990. J.A. 10057. The reference describes a âfluidic connection system . . . for draining liquids from and introducing liquids to patients.â J.A. 10059. As described by the reference, the system, which amounts to a wound dressing, consists of: [A] semipermeable membrane including a pair of panels each having a perimeter and an edge strip. The membrane is formed by connecting the panel edge strips together to form a seam extending transversely across the membrane. The panels and the membrane include inner and outer surfaces. A tube opening extends through the seam between the panel edge strips and between the membrane inner and outer surfaces. The membrane inner surface is coated with an adhesive for attachment to the skin of a patient. A tube or sheath includes a proximate end extending through the tube opening and a distal end positioned in spaced relation from the membrane outer surface. . . . A passage extend[s] through the KINETIC CONCEPTS v. SMITH & NEPHEW 10 sheath between its ends. An inner conduit can be placed in the sheath passage and can include a connection seal assembly for forming a fluid-tight seal with the sheath. . . . When the fluidic connection system is used as a wound dressing, an intermediate layer of material can be applied between the wound and the cover membrane inner surface. Furthermore, the fluidic connection system of the present invention can be used to secure a percutaneous drainage tube within a patient, e.g. by inserting the percutanious tube through the sheath passage. . . . The cover membrane can be releasably, adhesively fastened to the skin around a periphery thereof. A tube fluidically communicates with the wound through an opening in the membrane. Fluids from a draining wound can be evacuated through the tube and liquid medication and irrigation can be introduced through the tube to the wound site. The fluid evacuation and introduction steps of the method can each be accomplished both actively and passively . . . . J.A. 10061â63. The reference indicates that this wound dressing âpromotes healing.â J.A. 10063. C. Chariker-Jeter References The Chariker-Jeter references consist of two published articles (âChariker-Jeter Iâ and âChariker-Jeter II,â respectively), J.A. 10044â47; J.A. 10050â56, and Dr. Charikerâs 1989 public use of the system described in the articles on Gary Aderholt (âChariker-Jeter public useâ). Both Chariker-Jeter I and Chariker-Jeter II describe the same âclosed wound drainage system.â J.A. 10052. As described in Chariker-Jeter II, the drainage system is created by: 11 KINETIC CONCEPTS v. SMITH & NEPHEW 1. Irrigat[ing] the wound bed thoroughly with normal saline using a 30ml syringe with a 19gauge needle. 2. Moisten one 2X2 gauze square with normal saline. Open completely and lay across the wound bed. 3. Place Jackson-Pratt drain in wound bed. Shorten the fenestrated drain as necessary so that the flat drain is confined to the wound bed. The drain is never placed in the fistula 2 tract. In the case of fistula drainage at skin level, the fenestrated portion of the drain is simply centered over the cutaneous opening. It may be helpful to encircle the cutaneous wound with a pectin-based skin barrier in order to create a âtroughâ in which to situate the fenestrated drain. 4. Saturate 4X4 gauze squares with normal saline. Open and fluff into wound to completely cover the drain and fill the defect to skin level. In the case of a cutaneous fistula, only enough moist gauze to cover the flat fenestrated drain is required. 5. Apply skin sealant (Bard Barrier Film, SkinPrep, etc.) to all skin that will be covered by the film dressing. Allow to dry until slick. 6. Cut the film dressing or select a size to allow at least 1inch of intact skin beyond the wound edges. Place the film dressing over the packed wound. Carefully crimp the adhesive film dressing around the Jackson-Pratt tube to seal. 7. âCaulkâ the tube exit site with a small amount of Stomahesive Paste where the film dressing is A âfistulaâ is generally considered to be a hole in an organ. Kinetic Concepts, Inc. v. Blue Sky Med. Grp., Inc., 554 F.3d 1010, 1016 (Fed. Cir. 2009). 2 KINETIC CONCEPTS v. SMITH & NEPHEW 12 crimped around the tube. This ensures air-tight closure. 8. Reinforce this site with waterproof âpink tapeâ as illustrated. 9. Turn your attention now to the connection of the Jackson-Pratt to continuous suction. (Do not attempt to use the bulb of the Jackson-Pratt system.) With some brands of canister and tubing, all that is necessary is to cut the funnel end off the tubing and the small J-P tubing will fit snugly into the larger lumen tube. The junction should be taped securely with pink tape. Otherwise you may use small âChristmas treeâ connector or cannibalize IV tubing to get a small plastic adapter to connect the tubing. 10. Turn on continuous suction to the upper range of the low setting (approximately 60 to 80 mmHg) and observe the wound site. The dressing should contract noticeably. If it does not, the system is not closed and wound drainage will not be efficiently removed. When this occurs, fistula drainage will accumulate, causing skin damage and leakage outside of the dressing. Another indication that you have not obtained a closed suction system is a whistling sound indicating that the dressing is not air-tight. J.A. 10052 (footnote added). Chariker-Jeter II explains that â[o]ur clinical observations suggest that fistula effluent does inhibit wound healing. . . . By minimizing the inflammatory response [associated with the presence of effluent], fibroplasia is reduced. This, we believe, encourages rapid wound contraction and reepithelialization.â J.A. 10055. Finally, with respect to the Chariker-Jeter public use, Dr. Chariker testified that he treated Mr. Aderholt in 13 KINETIC CONCEPTS v. SMITH & NEPHEW 1989 with his closed suction wound drainage system. â[Mr. Aderholt] was injured with a log chain that flew off another truck into his truck, entered his chest, his abdomen, ruptured his lung, his [diaphragm], his pancreas, his spleen, his stomach.â J.A. 22032:8â11. With the aid of pictures of Mr. Aderholtâs treatment, Dr. Chariker stated that his treatment was an example of the drainage system facilitating the healing of a wound on a patient without a fistula. J.A. 22035:6â38:11. III. Prior Litigation In 2003, Wake Forest and KCI sued Blue Sky Medical Group, Inc., (âBlue Skyâ) et al., alleging that its gauze based negative pressure wound therapy products infringed U.S. Patent No. 5,636,643 3 (ââ643 patentâ) and the â081 patent. At trial, a jury found the patents were not infringed, not invalid, and not unenforceable. At the close of trial, defendants filed a motion for judgment as a matter of law, alleging that the asserted claims of the â643 and â081 patents were invalid as obvious under 35 U.S.C. Â§ 103. The district court denied that motion. On appeal, this court affirmed the juryâs finding that invalidity was not established and that the asserted claims were not infringed. Blue Sky, 554 F.3d at 1025â26. In reaching that conclusion, however, we determined that the district court committed harmless error by failing to construe the term âwound.â Id. at 1019. While we did not provide a definitive construction of âwound,â we concluded that construing â âwoundâ to include fistulae and âpus pocketsâ would  expand the scope of the claims far beyond anything described in the specification.â Id. Significantly, for the present appeal, we also concluded that âwound,â âas used in the asserted patents, does not cover KCI has not asserted this patent in the present litigation. 3 KINETIC CONCEPTS v. SMITH & NEPHEW 14 the fistulae described in the Chariker-Jeter publications . . . .â Id. at 1018. IV. Present litigation During the appeal in the prior litigation, S&N acquired Blue Sky. In December 2008, S&N announced it was launching a new foam-based negative pressure wound treatment product. Responding to this announcement, Wake Forest and KCI filed this suit, asserting that S&Nâs Renasys product infringed the asserted patents. After conducting a Markman hearing, the district court construed various terms recited in the claims. For this appeal, the courtâs construction of only the term âwoundâ is relevant; it construed this term to mean: âtissue damage to the surface of the body, including the epithelial and subcutaneous layers, and excluding fistulae and pus pockets.â Kinetic Concepts, Inc. v. Blue Sky Med. Grp., Inc., No. 08-cv-102, slip op. at 8 (W.D. Tex. Nov. 12, 2009) (claim construction order) (ECF No. 280) (âClaim Construction Orderâ); see also JMOL Order at 4. Before the case was given to the jury for determination, the parties disagreed about the form and content of the jury instructions. Wake Forest and KCI had demanded a trial by jury. In response, S&N moved the district court to strike the jury demand with respect to questions of law, including the ultimate question of obviousness. Def.âs Mot. to Strike Pls.â Jury Demand on Questions of Law at 5â9, Kinetic Concepts, Inc. v. Blue Sky Med. Grp., Inc., 08-cv-102 (W.D. Tex. Jan. 21, 2010) (ECF No. 397) (âMotion to Strikeâ). Prior to ruling on the merits of the motion to strike, the district court conducted an on-the-record pre-trial hearing. During the hearing, S&N made clear that it wanted the jury to make findings with respect to the factors under Graham v. John Deere Co. of Kansas City, 383 U.S. 1 (1966), and reserve the 15 KINETIC CONCEPTS v. SMITH & NEPHEW ultimate question of obviousness for the judge. Pre-Trial Conference Tr. at 16â22, Kinetic Concepts, Inc. v. Blue Sky Med. Grp., Inc., No. 08-cv-102 (W.D. Tex. Jan. 25, 2010) (âPre-Trial Conference Transcriptâ). To facilitate this division of responsibility, S&N proposed a special interrogatory verdict form: [T]he way itâs done and the way the models show . . . is the jury make[s] findings under Graham v. John Deere. If the jury is actually asked what is the level of skill in the art, thatâs one of the Graham findings. What is the scope and content of the prior art. . . . [W]e proposed and gave to KCI a two-page set of questions where we are specifically asking the jury to make findings as to whether or not the prior art contains a particular suggestion. Id. at 16. Under this proposal, the trial judge would resolve the ultimate question of obviousness on the basis of the juryâs factual findings as exemplified in their answers to the interrogatories. Wake Forest and KCI expressed the belief that this proposal was âone of the worst ideas of all timeâ because it would make the process so complicated that the jury could not get it right, thereby âtaking away from the jury the power they have been given by the constitution.â Id. at 23. Highlighting their concern with S&Nâs proposed verdict form, Wake Forest and KCI explained that: âItâs not two pages, but actually five pages of questions. Two pages that look like this of detailed questions about whether the prior art discloses teeny tiny aspects of the patent, and two questions that call for a narrative answer from the jury.â Id. at 26. Responding to this criticism, the trial judge indicated that he was âvery reluctant . . . to KINETIC CONCEPTS v. SMITH & NEPHEW 16 give juries questions requiring narrative answers.â Id. at 27. The trial judge summarized the partiesâ arguments as both saying essentially the same thing: â[N]o matter how I present this to the jury I have to make a separate determination as to obviousness. Even if I were to submit this to the jury in a broad form submission â just is it obvious â regardless of what the jury said, my analysis would have to require that I do my own look at the matter from a legal point of view . . . .â Id. at 30. The trial judge concluded the discussion of the Motion to Strike by indicating that he would read the materials presented by the parties and consider using special interrogatories. He cautioned, however, that, âwhile Iâm open to a special interrogatory presentation, Iâm not open to a special interrogatory presentation that goes on and on and on.â Id. at 30â31. Four days after conducting the pre-trial hearing, the district court denied S&Nâs request that it not submit the ultimate question of obviousness to the jury. Kinetic Concepts, Inc. v. Blue Sky Med. Grp., Inc., No. 08-cv-102, slip op. at 4â5 (W.D. Tex. Jan. 29, 2010) (order granting in part and denying in part defendantâs motion to strike plaintiffâs jury demand on questions of law) (ECF No. 407). It concluded that â[t]he jury instructions shall explain the underlying factual issues that the jury must resolve as well as the legal standard for determining obviousness. Additionally, the jury verdict form shall specifically ask the jury to determine the underlying Graham factors, and make a final determination of obviousness that the court will consider as advisory.â Id. at 5. In accordance with this ruling, the parties began developing proposed joint jury instructions and a special verdict form. At the close of the presentation of evidence, 17 KINETIC CONCEPTS v. SMITH & NEPHEW the parties were still developing the instructions and the verdict form. Jury Trial Tr. Day 10 at 2806, Kinetic Concepts, Inc. v. Blue Sky Med. Grp., Inc., No. 08-cv-102 (W.D. Tex. Feb. 23, 2010) (âDay 10 Trial Transcriptâ). Because the jury instructions and verdict form were not complete and there was some disagreement over the exact form the documents should take, the district court held a charge conference to resolve any remaining disputes, and finalize the instructions and the verdict form. At this stage in the proceeding, the obviousness verdict form proffered by S&N was eighteen pages in length, and Wake Forest and KCIâs was slightly more than seven pages in length. Id. at 2969â70. Each of the proposed verdict forms contained specific questions addressing the differences, if any, between the asserted claims and the three categories of prior art discussed above. After reviewing the proposals, the judge stated, âI really canât give them this. . . . I may have to try to figure out something else to give them, but this wonât work.â Id. at 2985. The judge explained his belief that, if the verdict form only posed the ultimate question to the jury, the court would be left with little guidance regarding the factual predicate for the juryâs resolution of that issue. Id. at 2990â91. The district court, therefore, expressed its preference to ask the jury specific questions about the various Graham factors, in addition to asking the jury its view on the ultimate conclusion of obviousness. Id. at 2992â94. After discussing the various options with the parties, the judge decided that the best option was to allow the parties to draft a 300-word description of what the parties asserted were the differences between the three main categories of prior art and each of the asserted claims. These âjury contentionsâ would be included in the jury instructions. Then the jury verdict form would ask what KINETIC CONCEPTS v. SMITH & NEPHEW 18 differences, if any, the jury found between the given claim and the three main categories of prior art, providing space for the jury to list the differences in a narrative. Id. at 2997â3006. With these guidelines, the judge dismissed the parties to finish drafting the jury instructions and verdict form, explaining that that they would meet that evening when the instructions and verdict form were complete. Id. at 3003â04. The judge advised the parties, however, that âif youâve got any better idea on obviousness that you can agree to, Iâll be glad to do it, but what youâve come up with so far weâre not going to do. And so, if you canât come up with anything, then you just have to do it the way I said, which I think is not optimal.â Id. at 3062. When the parties met that night with the judge, a court reporter was not present, so there is no record of the discussion. It is clear from looking at the jury instructions and the verdict form as presented to the jury, however, that the parties and the judge agreed to use a different format than suggested by the judge at the close of the charge conference. Although the jury instructions contain a discussion of the partiesâ contentions regarding the differences between the prior art and the claims, Jury Trial Tr. Day 11 at 3098â3102, Kinetic Concepts, Inc. v. Blue Sky Med. Grp., Inc., No. 08-cv-102 (W.D. Tex. Feb. 24, 2010) (âDay 11 Trial Transcriptâ), the verdict form did not allow the jury to provide a narrative about which differences they found to exist, nor did it pose questions regarding all of the Graham factors. J.A. 65â89. Instead, in questions 5(A)â(C), the jury was asked whether several enumerated differences between the prior art and the asserted claims were the only differences that existed. The jury was simply instructed to answer yes or no. In addition, in question 5(D), the verdict form contained a chart that allowed the jury to indicate whether they found 19 KINETIC CONCEPTS v. SMITH & NEPHEW certain objective indicia of nonobviousness to be present with respect to each of the asserted claims. J.A. 70. Finally, in question 6, the verdict form asked the jury to decide whether S&N had proven that the asserted claims were obvious. J.A. 71. The jury determined that the claims and the prior art exhibited differences in addition to those listed, J.A. 64â 69, that most of the objective considerations favoring nonobviousness were present with respect to each claim, that infringement was proven, and that obviousness was not established. J.A. 62â63; 71. After the verdict was read to the parties, the district court indicated that the parties should prepare post-trial motions if they wished to challenge the juryâs verdict. Jury Verdict Tr. at 12â13, Kinetic Concepts, Inc. v. Blue Sky Med. Grp., Inc., No. 08cv-102 (W.D. Tex. Mar. 10, 2010) (âJury Verdict Transcriptâ). Pursuant to Rule 50(b) of the Federal Rules of Civil Procedure, S&N moved for JMOL, arguing that all of the asserted claims of the â081 and â651 patents were obvious. In its motion, S&N asserted that substantial evidence did not support the juryâs explicit findings that (1) additional differences between the prior art and the asserted claims existed, and (2) that multiple objective indicia of nonobviousness were present. Responding to S&Nâs motion, Wake Forest and KCI argued that, in addition to the explicit jury findings, the juryâs implicit findings necessary to determine the ultimate question of obviousness should be presumed to have been found in Wake Forest and KCIâs favor. Furthermore, these findings, both explicit and implicit, should not be disturbed by the trial court unless they are not supported by substantial evidence. In light of this standard, Wake Forest and KCI asserted that substantial evidence KINETIC CONCEPTS v. SMITH & NEPHEW 20 supported the juryâs factual determinations: (1) that additional differences existed between the prior art and the asserted claims; (2) that objective indicia of nonobviousness were present; and (3) that teaching away was demonstrated with respect to the Bagautdinov and Chariker-Jeter references. On the basis of these findings, Wake Forest and KCI asserted that S&Nâs motion should be denied because it failed to establish that the asserted claims were obvious as a matter of law. Replying to Wake Forest and KCI, S&N highlighted that the juryâs verdict of nonobviousness was advisory only. Accordingly, it argued that there were no implicit factual findings in support of the advisory verdict on nonobviousness to which the court should defer. Instead, S&N asserted that âas the ultimate decision-maker on obviousness, th[e] [district] [c]ourt has the responsibility to make its own findings, based upon the current record, necessary to support its own legal conclusion regarding obviousness.â Def.âs Reply in Supp. of its Renewed Mot. for J. as a Matter of Law of Invalidity for Obviousness and Mot. for New Trial at 1, Kinetic Concepts, Inc. v. Blue Sky Med. Grp., Inc., No. 08-cv-102 (W.D. Tex. May 12, 2010) (ECF No. 548). Based upon this understanding of how the juryâs verdict should be reviewed by the district court, S&N argued that the asserted claims were obvious as a matter of law. Prior to ruling on the merits of S&Nâs motion, the court conducted a hearing. S&N began by arguing that, because the juryâs verdict on the ultimate question of obviousness was advisory, it is inappropriate to âjust assume every finding of fact in favor ofâ the juryâs nonobviousness verdict. Post-Trial Hrâg Tr. at 133, Kinetic Concepts, Inc. v. Blue Sky Med. Grp., Inc., No. 08-cv-102 (W.D. Tex. May 17, 2010) (âPost-Trial Hearing Transcriptâ). Indeed, S&N argued that implied findings of fact 21 KINETIC CONCEPTS v. SMITH & NEPHEW only arose with respect to questions 5(A)â(C), regarding additional differences, and 5(D), regarding the existence of objective indicia of nonobviousness. Id. at 133â34, 36. âIt is not simply enough to say the jury found obviousness, implied every finding of fact in our favor, which is what KCI is arguing, and therefore the verdict should be upheld. Not true. They are only entitled to implied findings to the extent they are encompassed by the Verdict Question 5, not 6.â Id. at 136. S&N argued that substantial evidence did not support the juryâs factual finding that additional patentably significant differences existed between the prior art and the asserted claims and that objective indicia of nonobviousness were present. Wake Forest and KCI, on the other hand, argued that the juryâs verdict on the ultimate question of obviousness is always advisory because, as a question of law, it must be determined by the court. See id. at 153. Nonetheless, âthe case law is absolutely clear that . . . [w]hen the jury finds that [the claims] are not obvious, you have to assume that they find the right underlying facts, and then the test is substantial evidenceâ for the underlying factual findings. Id. at 155. Under this standard, Wake Forest and KCI argued that substantial evidence supported the juryâs explicit and implicit factual findings, and that S&Nâs motion should have been denied. Ultimately, the district court indicated that it would âreview the juryâs conclusions on obviousness, a question of law, without deference, and the underlying findings of fact, whether explicit or implicit within the verdict, for substantial evidence.â JMOL Order at 8. After thoroughly summarizing the relevant prior art, the district court concluded that, contrary to the juryâs explicit findings, âthe differences between the claimed invention and the prior art, if any, are minimal.â Id. at 18. Indeed, the district court concluded that the differences were so minor KINETIC CONCEPTS v. SMITH & NEPHEW 22 that âsuch minimal variations would have been apparent to one having ordinary skill in the art . . . .â Id. at 34. The court concluded, therefore, that âthe evidence is clear and convincing that there is no legally sufficient basis on the record to conclude that all asserted claims of the patents in suit were not obvious.â Id. The fact that the jury also found that several objective indicia of nonobviousness were present did not alter the district courtâs conclusion because, it said, âthe Court is not convinced that they overcome the strong case of obviousness established by the teaching in the prior art.â Id. at 35. Accordingly, the court granted S&Nâs motion and entered judgment in its favor. Id. at 37. Wake Forest timely appealed. 4 We have jurisdiction pursuant to 28 U.S.C. Â§ 1295(a)(1). DISCUSSION We review a district courtâs grant of JMOL de novo, applying the law from the regional circuit, the Fifth Circuit in this case. Harris Corp. v. Ericsson Inc., 417 F.3d 1241, 1248 (Fed. Cir. 2005). In the Fifth Circuit, JMOL may be granted by the trial court only if âthe facts and inferences point so strongly and overwhelmingly in favor of one party that the Court believes that reasonable men could not arrive at a contrary verdict . . . . On the other hand, if there is substantial evidence opposed to the [grant of JMOL] . . . [it] should be denied.â Broussard v. State Farm Fire & Cas. Co., 523 F.3d 618, 624 (5th Cir. 2008) (quoting Brown v. Bryan Cnty., 219 F.3d 450, 456 (5th Cir. 2000)). When evaluating the district courtâs grant of JMOL, consideration is given to âall of the evidence, drawing all reasonable inferences and resolving all credibility determinations in the light most favorable to KCI did not appeal this judgment and is not, therefore, an appellant before this court. 4 23 KINETIC CONCEPTS v. SMITH & NEPHEW the non-moving party.â Id. (quoting Brown, 219 F.3d at 456. Because obviousness is a mixed question of law and fact, â[w]e first presume that the jury resolved the underlying factual disputes in favor of the verdict  and leave those presumed findings undisturbed if they are supported by substantial evidence. Then we examine the [ultimate] legal conclusion [of obviousness] de novo to see whether it is correct in light of the presumed jury fact findings.â Jurgens v. McKasy, 927 F.2d 1552, 1557 (Fed. Cir. 1991) (internal citations omitted); see also Bos. Scientific Scimed, Inc. v. Cordis Corp., 554 F.3d 982, 990 (Fed. Cir. 2009) (âWhen we consider that, even in light of a juryâs findings of fact, the references demonstrate an invention to have been obvious, we may reverse its obviousness determination.â (citing Richardson-Vicks, Inc. v. Upjohn Co., 122 F.3d 1476, 1479 (Fed. Cir. 1997))). In the face of what amounts to well settled law, S&N argues that, because the juryâs verdict in this case was âadvisory,â âno factual findings implied within the advisory verdict are binding . . . .â Appelleeâs Br. at 39. S&N asserts, therefore, that we should review only the juryâs explicit factual findings with respect to questions 5(A)â(D) for substantial evidence. Because the juryâs advisory verdict on the ultimate question of obviousness gave rise to no implied factual findings, S&N contends the district court was free to make its own findings of fact with respect to all issues not submitted to the jury. Id. at 39â40. According to S&N, we should review these factual findings for clear error. Finally, S&N argues that the district courtâs ultimate conclusion regarding obviousness should be reviewed de novo in light of the factual findings we find to be supported by the evidence. We disagree. Although S&N is correct that the district court repeatedly referred to the jury in this case as âadvisory,â S&N is wrong about the implications use of that term KINETIC CONCEPTS v. SMITH & NEPHEW 24 carries. We first address the ways in which the phrase âadvisory juryâ is used by trial courts. The term is sometimes used to refer to Rule 39(c)(1) juries. Fed. R. Civ. P. 39(c)(1) (âIn an action not triable of right by a jury, the court, on motion or on its own: may try any issue with an advisory jury . . . .â). Under Rule 39(c)(1), when an âadvisory juryâ is used, no jury findings â either explicit or implicit â are binding on the trial court and the court is obligated to make independent findings of fact and conclusions of law on the issue presented to the jury. S&N first claims that the district court submitted the matter to the jury under Rule 39(c)(1) and that accordingly, neither the trial court nor we are bound by the juryâs factual findings. We disagree. We do not believe that the district court intended to invoke Rule 39(c)(1) when it referred to an âadvisory jury.â First, a Rule 39(c)(1) advisory jury is available only in an action not triable by right to a jury. Id. But, patent infringement actions must be tried to a jury if demanded by a party. Markman v. Westview Instruments, Inc., 517 U.S. 370, 377 (1996). Second, S&N did not ask and the district court did not make special findings that Rule 52 requires in all actions tried âwith an advisory jury.â Fed. R. Civ. P. 52 (â[T]he court must find the facts specially and state its conclusions of law separately.â); see also Transmatic, Inc. v. Gluton Indus., Inc., 53 F.3d 1270, 1275 (Fed. Cir. 1995) (âWhen, as here, trial is held before the district court with an advisory jury, the court must find the facts specially just as it would when conducting a bench trial without an advisory jury.â (citing In re Incident Aboard the D/B Ocean King, 758 F.2d 1063, 1072 (5th Cir.1985))). And, rather than filing a motion to have the judgment amended under Rule 52(b), which applies to actions tried before a Rule 39(c)(1) advisory jury, S&N filed a motion pursuant to Rule 50, which governs âjudg- 25 KINETIC CONCEPTS v. SMITH & NEPHEW ment as a matter of law in a jury trial.â 5 Fed. R. Civ. P. 50. Finally, S&N concedes that the district court, and we, must defer to the juryâs explicit factual findings, a concession that is inconsistent with its reliance on Rule 39(c)(1). It is clear, therefore, that the court did not use the term âadvisory juryâ to denote a Rule 39(c)(1) jury. 6 As a consequence, all of the cases cited by S&N for the proposition that there are âno factual findings implied During oral argument, S&N argued that this courtâs decision in Goodwall Construction Co. v. Beers Construction Co., 991 F.2d 751 (Fed. Cir. 1993) required it to file its motion under Rule 50 and not Rule 52(b). Oral Argument at 30:12â30:49, Kinetic Concepts, Inc., v. Smith & Nephew, Inc., No. 2011-1105, available at http://www.cafc.uscourts.gov/oral-argumentrecordings/2011-1105/all. Goodwall does not address this issue, however. Instead, it addresses whether a motion on an issue unresolved by the jury, which utilized a Rule 49(a) special verdict form, is a motion for judgment under Rule 49(a) or Rule 50(b). 991 F.2d at 756â57. We held that it was a motion under Rule 49(a). Id. at 757. 6 To the extent S&N argues that KCI waived its right to a jury trial, and agreed to use a Rule 39(c)(1) jury, we find no merit in this argument. Waiver of the right to a jury trial cannot be assumed under circumstances in which a party continually requests a jury trial and the district court never referenced Rule 39 or waiver of the right to a jury trial when it referred to an âadvisory jury.â See Jennings v. McCormick, 154 F.3d 542, 545 (5th Cir. 1998) (âThe right to jury trial is too important and the usual procedure for its waiver is too clearly set out by the Civil Rules for courts to find a knowing and voluntary relinquishment of the right in a doubtful situation.â (citation omitted)); McDonald v. Steward, 132 F.3d 225, 229 (5th Cir. 1998) (âWaiver should not be found in a doubtful situation.â (internal quotation and citation omitted)); McAfee v. Martin, 63 F.3d 436, 437 (5th Cir. 1995) (â[C]ourts should indulge every reasonable presumption against waiver.â (internal quotation and citation omitted)). 5 KINETIC CONCEPTS v. SMITH & NEPHEW 26 within the advisory verdict [that] are binding on the district courtâ are irrelevant because all of the cases involved actions that are not triable to a jury by right and all addressed Rule 39(c)(1) advisory juries. E.g., Am. Calcar, Inc. v. Am. Honda Motor Co., 651 F.3d 1318, 1333 (Fed. Cir. 2011) (âInequitable conduct is equitable in nature, with no right to a jury, and the trial court has the obligation to resolve the underlying facts of materiality and intent.â (citation omitted)); Sheilaâs Shine Prods., Inc. v. Sheila Shine, Inc., 486 F.2d 114, 122 (5th Cir. 1973). Whether the juryâs verdict on obviousness gave rise to implied factual findings is not, therefore, controlled by these cases. The term âadvisory juryâ can also be used to denote a juryâs resolution of a legal issue that the court can permissibly give to the jury to decide, but whose ultimate determination is reserved for the court. See e.g., Spectralytics, Inc. v. Cordis Corp., 649 F.3d 1336, 1341â42 (Fed. Cir. 2011); R.R. Dynamics, Inc. v. A. Stucki Co., 727 F.2d 1506, 1515 (Fed. Cir. 1984). As we have explained: [I]t is neither error nor dangerous to justice to submit legal issues to juries, the submission being accompanied by appropriate instructions on the law from the trial judge. The rules relating to interrogatories, jury instructions, motions for directed verdict, JNOV, and new trial, and the rules governing appeals following jury trials, are fully adequate to provide for interposition of the judge as guardian of the law at the proper point and when necessary. There is no question that the judge must remain the ultimate arbiter on the question of obviousness. He or she exercises that role first in exercising the judgeâs duty of giving proper instructions on the law to the jury before it considers its verdict. The judge exercises control 27 KINETIC CONCEPTS v. SMITH & NEPHEW on the question again when presented with a motion for JNOV or new trial. In no sense need the judge abdicate the guardianship role. R.R. Dynamics, 727 F.2d at 1515. This appears to be the manner in which the district court used the term âadvisory jury.â Pre-Trial Conference Transcript at 16â22 (â[N]o matter how I present this to the jury I have to make a separate determination as to obviousness.â). This conclusion is buttressed by the fact that the Patent Case Management Judicial Guide, which the district court explained it reviewed with respect to this issue, suggests this use of the term âadvisory jury.â Peter S. Menell et al., Patent Case Management Judicial Guide 8-32 (2009) (â[T]he court can submit only the relevant Graham factors to the jury for its determination through special interrogatories, with or without an advisory verdict on the legal question of obviousness, and then determine the ultimate question of obviousness itself based on the juryâs factual determinations.â). With this understanding of the district courtâs use of the term âadvisory jury,â we now address S&Nâs remaining argument regarding the standard of review. S&N asserts that the district court utilized a Rule 49(a) special interrogatory verdict form. Based on this contention, S&N asserts that there are no implied factual findings to which deference is due because a party waives its right to a jury trial on factual issues for which the party did not demand a special interrogatory and âfactual issues not submitted to the jury as special interrogatories are deemed decided by the district court in accordance with the courtâs judgment.â Appellee Br. at 40. S&N is incorrect. First, a court employing a Fed. R. Civ. P. 49 special verdict form can only require the jury to return such findings as to âeach issue of fact.â Rule KINETIC CONCEPTS v. SMITH & NEPHEW 28 49(a)(1). Because the ultimate conclusion of obviousness is a legal question, there is strength to the argument that by including that question on its verdict form the court chose to employ a general verdict with answers to written questions governed by Rule 49(b). It is clear that factual findings in support of the general verdict are implied when a verdict form under Rule 49(b) is used. See Quaker City Gear Works, Inc. v. Skil Corp., 747 F.2d 1446, 1453 (Fed. Cir. 1984) (explaining that when a Rule 49(a) verdict form includes a legal question, âsince the answer to the legal question necessarily resolves any disputed underlying factual issues, we have undertaken to review the factual findings on which the legal conclusion is based, applying the substantial evidence standard.â (citation omitted)). Furthermore, we have indicated that, while it is not error to submit legal questions to the jury as part of a Rule 49(a) special verdict form, âsince the answer to the legal question necessarily resolves any disputed underlying factual issues,â the court must accept implicit factual findings upon which the legal conclusion is based when they are supported by substantial evidence. Id. (citing Connell v. Sears, Roebuck & Co., 722 F.2d 1542, 1550 (Fed. Cir. 1983)); see also Gia Techs. Inc. v. Recycled Prods. Corp., 175 F.3d 365, 371 (5th Cir. 1999) (âRule 49(a) does not permit a district court to make findings contrary to the jury verdict.â). In essence, because the district court included the ultimate question of obviousness on the special verdict form, all of the factual determinations underlying the ultimate question were implicitly put to the jury for resolution. Wake Forest did not, therefore, waive a jury trial on any factual issue not submitted to the jury in an interrogatory, and the district court was required to accept all implicit factual findings supporting the juryâs conclusion with respect to the ultimate conclusion of obviousness that were supported by substantial evidence. 29 KINETIC CONCEPTS v. SMITH & NEPHEW Accordingly, we review all of the juryâs explicit and implicit factual findings for substantial evidence. We then examine the legal conclusion of obviousness de novo to determine whether it is correct in light of the factual findings that we find adequately supported. Jurgens, 927 F.2d at 1557. I. A patent is obvious, and, therefore, invalid âif the differences between the subject matter sought to be patented and the prior art are such that the subject matter as a whole would have been obvious at the time the invention was made to a person having ordinary skill in the art to which said subject matter pertains.â 35 U.S.C. Â§ 103(a). Obviousness is a question of law based on underlying factual findings: (1) the scope and content of the prior art; (2) the differences between the claims and the prior art; (3) the level of ordinary skill in the art; and (4) objective indicia of nonobviousness. Graham, 383 U.S. at 17â18. A party seeking to invalidate a patent on the basis of obviousness must âdemonstrate âby clear and convincing evidence that a skilled artisan would have been motivated to combine the teachings of the prior art references to achieve the claimed invention, and that the skilled artisan would have had a reasonable expectation of success in doing so.â â Procter & Gamble Co. v. Teva Pharm. USA, Inc., 566 F.3d 989, 994 (Fed. Cir. 2009) (quoting Pfizer, Inc. v. Apotex, Inc., 480 F.3d 1348, 1361 (Fed. Cir. 2007)). While an analysis of any teaching, suggestion, or motivation to combine elements from different prior art references is useful in an obviousness analysis, the overall inquiry must be expansive and flexible. KSR Intâl Co. v. Teleflex, Inc., 550 U.S. 398, 415, 419 (2007). This court has explained, moreover, that the obviousness inquiry requires examination of all four Graham KINETIC CONCEPTS v. SMITH & NEPHEW 30 factors. E.g., Mintz v. Dietz & Watson, Inc., 679 F.3d 1372, 1375 (Fed. Cir. 2012). Indeed, courts must consider all of the Graham factors prior to reaching a conclusion with respect to obviousness. In re Cyclobenzaprine Hydrochloride Extended-Release Capsule Patent Litig., 676 F.3d 1063, 1076â77 (Fed. Cir. 2012) (collecting cases). At all times, the burden is on the defendant to establish by clear and convincing evidence that the patent is obvious. Id. at 1077â78. Because Wake Forest asserts that the district court erred by granting judgment as a matter of law overturning the juryâs verdict, we must determine which of the juryâs explicit and implicit factual findings with respect to the Graham factors are supported by substantial evidence. Each of the Graham factors is addressed in turn below. A. Scope and Content of the Prior Art The parties agree on which references are prior art. On appeal, S&N focuses its obviousness analysis on the Bagautdinov references, Zamierowski reference, and the Chariker-Jeter references. With respect to these references, the parties dispute their content, 7 namely, whether the prior art discloses the treatment of wounds with negative pressure. This is the central issue on appeal because all of the asserted claims, covering either the method or apparatus, require the use of negative pressure to either âtreat a woundâ or âfacilitate the healing of While the district court stated that the parties did not contest the content of the prior art, this statement was incorrect. JMOL Order at 7. Whether the prior art disclosed the treatment of wounds with negative pressure was a key dispute between the parties, see id. at 21, and the district court resolved the issue in its JMOL order. Id. at 25, 27â28, 33. 7 31 KINETIC CONCEPTS v. SMITH & NEPHEW wound.â 8 The district court concluded that there was no support for the proposition that these primary references did not disclose the treatment of wounds utilizing negative pressure. JMOL Order at 25, 27â28, 33. As explained below, this was error: substantial evidence supports the juryâs implied factual finding that none of these references disclosed the treatment of wounds using negative pressure. 1. Content of the Bagautdinov References The Bagautdinov references disclose a device for draining fluid from purulent wounds. The device involves placement of a polyurethane foam in the purulent wound, attaching the foam to a pump, and covering the apparatus and the wound with a polyethylene film secured to the skin with vaseline oil. J.A. 10002. The jury was presented with conflicting evidence regarding whether the references treated wounds as construed by the district court, and if they did, whether they treated wounds with negative pressure. S&Nâs experts contended that the references disclosed the treatment of wounds within the meaning of the asserted claims. See J.A. 22345:13â17 (testimony of Dr. Gordon, S&Nâs expert, stating that Bagautdinov I disclosed the use of negative pressure to treat a wound). In addition, Dr. Bagautdinov displayed the method disclosed in the references to the jurors with the aid of a manikin. J.A. 22204â05. Wake Forest presented conflicting testimony, however. It proffered expert testimony that the purulent wounds described in the Bagautdinov references are in fact abscess or pus pockets not within the district courtâs While the district court indicated in the JMOL Order that it was not sure the claims contained this limitation, as explained below, they do. See infra p. 30. 8 KINETIC CONCEPTS v. SMITH & NEPHEW 32 construction of the term âwound.â J.A. 22871:19â21 (âDr. Bagautdinov is using a variant, or modification of a technique, to aspirate, or to suck out, pus from a purulent wound, which is a pus pocket.â); J.A. 21431:15â23 (discussing how Bagautdinov treated pus pockets by lancing and then draining them with the disclosed method). In addition, Wake Forestâs expert testified that the Bagautdinov references indicate that use of the device is discontinued when the purulent wound has been cleaned of infection, whereas the patented method and apparatus are utilized only after a wound has been cleaned of infection. J.A. 22878:7â80:16. S&Nâs expert conceded, moreover, that the Bagautdinov articles were âparticularly concerned about the problems related to putting negative pressure on the area of skin surrounding the wound and the risk of spreading infection, causing tissue damage . . . .â J.A. 22343:5â8. In other words, the Bagautdinov references explain that use of negative pressure on or surrounding a wound is dangerous to the patient. This amounts to teaching away. Ricoh Co. v. Quanta Computer Inc., 550 F.3d 1325, 1332 (Fed. Cir. 2008) (quoting In re Kahn, 441 F.3d 977, 990 (Fed. Cir. 2006) (âA reference may be said to teach away when a person of ordinary skill, upon reading the reference, would be discouraged from following the path set out in the reference, or would be led in a direction divergent from the path that was taken by the applicant.â)). Finally, Wake Forest presented testimony that the method disclosed in the Bagautdinov references could not create an adequate seal, J.A. 21437:25â38:2; J.A. 21433:2â15, and did not treat wounds through negative pressure because the pressure was not sustained for a long enough period of time. J.A. 21433:18â34:11; J.A. 21437:19â38:2. Indeed, Dr. Bagautdinov admitted that he only used his device to treat âinfected wounds,â J.A. 33 KINETIC CONCEPTS v. SMITH & NEPHEW 22312:15â22, and that he ânever considered using [his] technique to treat wounds until closure.â J.A. 22310:17â 21. Because of this conflicting expert testimony, the jury was free to âmake credibility determinations and believe the witness it considers more trustworthy.â Streber v. Hunter, 221 F.3d 701, 726 (5th Cir. 2000) (quotations omitted). In light of the juryâs determination that S&N failed to prove obviousness, we must infer that the jury found Wake Forestâs experts to be credible and persuasive on this point. Broussard, 523 F.3d at 624; Jurgens, 927 F.2d at 1557. Crediting their testimony over that of S&Nâs expert, there is substantial evidence supporting the factual finding that the Bagautdinov references do not disclose: (1) the treatment of âwoundsâ as described in patents; or (2) use of negative pressure to treat wounds. There is also substantial evidence to support the finding that the references teach away from maintaining negative pressure on a wound for extended periods of time because of the perceived problems associated with doing so. 2. Content of the Zamierowski Reference The parties agree that the Zamierowski referenceâs method is utilized on âwoundsâ within the district courtâs construction, and discloses placing a screen means into a wound, sealing the wound by placing a membrane with an adhesive coating over the wound, and connecting a tube from under the membrane to a vacuum source. J.A. 28. This system can then be used to either drain from or inject fluid into the wound. J.A. 10063. S&N argues, and the district court found, that the Zamierowski reference also disclosed treating wounds with negative pressure. JMOL Order at 27â28. During trial, Wake Forest argued that this reference does not disclose healing wounds with negative pressure KINETIC CONCEPTS v. SMITH & NEPHEW 34 because it neither disclosed a seal capable of maintaining negative pressure on a wound, nor disclosed treating the wound towards a selected stage of healing as required by the asserted method claims. The district court concluded that Wake Forestâs first argument was incorrect because it found that the patent claims do not require healing to be accomplished by negative pressure. Id. at 27. In the alternative, the district court concluded that the Zamierowski reference met this requirement because fluid is removed from the wound with negative pressure and removal of fluid enabled healing, so âhealingâ was âaccomplished by the negative pressure.â Id. at 27â28. The district court was incorrect with respect to its determination that the claims of the asserted patents do not require wounds to be healed by negative pressure. First, in the Blue Sky appeal, we concluded that all of the claims of the â081 patent asserted in the present litigation require the use of negative pressure to treat a âwound.â 554 F.3d at 1015 (â[E]ach of the asserted claims in both the â081 and â643 patents requires using âreducedâ or ânegativeâ pressure to âtreat a woundâ or âfacilitate the healing of a wound . . . .â). Thus, we have already construed the claims to include this limitation and that legal conclusion was binding on the district court and is binding on this panel. The specifications of both the â081 and â651 patents support our conclusion in Blue Sky, moreover. E.g., â081 patent col.2 ll.45â49 (âThe present invention includes . . . applying a negative pressure to a wound over an area sufficient to promote migration of epithelial and subcutaneous tissue toward the wound, with the negative pressure being maintained for a time sufficient to facilitate closure of the wound.â); â651 patent col.2 ll.61â64 (â[A] wound treatment apparatus is provided for treating a wound by applying reduced pressure . . . to the wound 35 KINETIC CONCEPTS v. SMITH & NEPHEW . . . .â). And, before the PTO, the patentees distinguished their claims from the prior art by asserting that references âdo not disclose or suggest âan appliance for administering a reduced pressure treatment to a woundâ; âan apparatus/method for treating a woundâ with reduced pressure.â J.A. 5501 (â651 patent); see also J.A. 5502 (â651 patent); J.A. 8267 (â081 patent) (Unlike the prior art, â[the] claimed invention is directed to a device configured to create and maintain negative pressure on a wound site . . . for the purpose of administering a negative pressure treatment to the wound.â). Finally, S&N never argued before the distri