Lidocaine Dosing for Nexplanon Removal and Reinsertion
For Nexplanon removal and reinsertion, use 0.5-1 mL of 1% lidocaine for removal and 2 mL of 1% lidocaine for reinsertion, totaling approximately 1.5-3 mL (15-30 mg) of 1% lidocaine for the complete procedure.
Specific Dosing by Procedure Component
For Removal
The FDA-approved Nexplanon label specifies 0.5 to 1 mL of 1% lidocaine injected at the removal site 1. This anesthetic should be injected under the implant to keep it close to the skin surface—injecting over the implant makes removal more difficult 1.
For Reinsertion
The FDA label recommends 2 mL of 1% lidocaine injected just under the skin along the planned insertion tunnel 1. This provides adequate anesthesia for the subdermal placement of the new device.
Safety Considerations
This total dose (15-30 mg) is well below maximum safe limits. For adults, the maximum safe dose is 4.5 mg/kg of lidocaine without epinephrine or 7.0 mg/kg with epinephrine 2. For a 70 kg woman, this translates to 315 mg without epinephrine or 490 mg with epinephrine—far exceeding what's needed for this procedure.
Critical Technical Points
Injection technique matters for both safety and efficacy:
- Always aspirate before injecting to avoid intravascular administration 2
- For removal: inject the anesthetic beneath the implant, not over it, to maintain superficial positioning 1
- For insertion: inject along the planned tunnel to anesthetize the entire tract 1
- Use incremental injections rather than a single bolus 2
Same-Day Removal and Reinsertion
When performing immediate reinsertion after removal, you can use the same incision if the site is in the correct anatomical location 1. The total lidocaine requirement remains 1.5-3 mL since you're using one incision site, though you may need the full 3 mL to adequately anesthetize both the removal dissection and the new insertion tunnel.
Common Pitfalls to Avoid
- Don't inject over the implant during removal—this pushes it deeper and complicates extraction 1
- Don't exceed 2 mm incision length for removal—larger incisions aren't necessary and increase complications 1
- Don't attempt removal if the implant is non-palpable without proper localization imaging; deeply placed implants require experienced operators 1, 3
The evidence shows that proper placement by experienced providers significantly reduces the need for surgical removal (only 1.9% required operative intervention in one large series) 3, emphasizing the importance of correct initial technique and adequate anesthesia.