Nexplanon Removal Technique
Nexplanon removal should be performed by a trained healthcare professional using a standardized technique: confirm implant location by palpation, make a 2-3mm longitudinal incision at the distal tip after local anesthesia, push down the proximal end to expose the tip, and extract with forceps—the procedure typically takes 3-5 minutes for palpable implants. 1
Pre-Removal Assessment
Before attempting removal, verify:
- Implant location by palpation of both ends of the 4cm rod
- Patient has no allergies to antiseptic or local anesthetic
- Review medical record to confirm which arm contains the implant if non-palpable 1
Critical warning: If the implant is non-palpable, do NOT attempt standard removal. Non-palpable implants require specialized localization and removal techniques 1.
Standard Removal Procedure (Palpable Implants)
Required Equipment
- Examination table
- Sterile surgical drapes, gloves, antiseptic solution, surgical marker
- Local anesthetic (0.5-1 mL of 1% lidocaine), needles, syringe
- Sterile scalpel, forceps (straight and curved mosquito)
- Skin closure materials, sterile gauze, pressure bandage 1
Step-by-Step Technique
Patient positioning: Have patient lie supine with arm flexed at elbow and hand underneath head 1.
Locate and stabilize: Push down the proximal end (closest to shoulder) to make the distal tip bulge and mark this location 1.
Anesthetize correctly: Inject 0.5-1 mL of 1% lidocaine under the implant to keep it close to skin surface. Injecting over the implant makes removal more difficult 1.
Incision: Make a 2mm longitudinal incision (parallel to implant) over the distal tip. Avoid cutting the implant itself 1.
Extraction:
- The tip should pop out of the incision
- Grasp with forceps and remove using gentle traction
- If needed, use blunt dissection to free adherent tissue
- If tip doesn't appear, insert curved mosquito forceps superficially into incision, grasp implant, and flip forceps over 1
Closure: Apply small adhesive bandage and pressure dressing for 24 hours 1.
Expected duration: Average removal time is 3.6-4.8 minutes for palpable implants 2, 3, 4.
Non-Palpable Implant Management
If implant cannot be palpated after insertion or at time of removal, STOP the standard procedure. 1
Localization Methods (in order of preference):
- Two-dimensional X-ray (Nexplanon contains barium sulfate for radiopacity)
- CT scan
- High-frequency ultrasound (≥10 MHz linear array transducer) 1, 5
- MRI as alternative imaging
- Etonogestrel blood level measurement if imaging fails (call manufacturer at 1-844-674-3200) 1
Specialized Removal Techniques
Non-palpable implants should only be removed by healthcare professionals experienced with deep implant removal 1, 3. Successful techniques include:
- Modified vasectomy clamp technique: After ultrasound localization, use modified vasectomy clamp through ≤5mm incision directly over implant 5
- Curved needle stabilization: Place prebent curved needle under implant to fix position, then dissect and extract 6
- Ultrasound-guided hydrodissection: For nerve-adjacent implants, use 50 mL D5W (without local anesthetic) to separate implant from neurovascular structures, then stabilize with 25-gauge needle for extraction 7
Removal time for non-palpable implants: Average 30 minutes with specialized techniques 6, though standard office removal averages 4.8 minutes through 2-3mm incision using ring forceps 3.
Common Pitfalls
Deeply inserted implants: May be located 2.7-12mm deep 3. These require imaging localization and should not be removed without proper visualization. Deeply placed implants should be localized and removed promptly to avoid potential distant migration 1.
Subfascial or intramuscular location: May require fascia opening along device axis with retractors 6. Consider referral to specialized center.
Previous failed removal attempts: 17% of referrals have had prior failed attempts 3. These cases benefit from ultrasound guidance and specialized techniques.
Implants near neurovascular structures: Can cause neuropathy 7. Use hydrodissection and ultrasound guidance to avoid nerve injury during removal.
Post-Removal Care
- Keep patient flat for 5 minutes with legs out of stirrups
- Gradually raise head of table to prevent vasovagal reaction
- Pressure bandage for 24 hours, adhesive bandage for 3-5 days 1
- NSAIDs (naproxen 440-550mg q12h or ibuprofen 600-800mg q6-8h) for 24 hours if needed 8
Key Safety Points
The FDA label emphasizes that removal complications are rare (0.2%) when proper technique is followed 2, 9. However, if you are unsure of removal steps, do not attempt the procedure—call 1-844-674-3200 for assistance 1. Regional expert centers should be established for difficult removal referrals 5.