What direction should the incision be made for Nexplanon (etonogestrel implant) removal?

Incision Direction for Nexplanon Removal

For Nexplanon removal, the incision should be made parallel to the implant, directly over it, following the same direction as the implant itself.

Proper Technique for Nexplanon Removal

Localization and Preparation

1. Palpate the implant to confirm its location and direction
2. Mark the distal end of the implant (the end closest to the elbow)
3. Clean the area with antiseptic solution
4. Administer adequate local anesthesia beneath the distal tip of the implant

Incision Technique

• Make a small incision (2-3mm) parallel to the implant at its distal end
• The incision should follow the same direction as the implant, not perpendicular to it
• Avoid making the incision at the insertion site, which is often at the proximal end
• For standard removals, a 2-3mm incision is typically sufficient

Extraction Process

1. After making the parallel incision, gently push the proximal end of the implant to make the distal end visible
2. Once visible, grasp the implant with ring forceps or small hemostats
3. Remove the implant with gentle traction
4. The average removal time is 4-5 minutes when proper technique is used 1

Special Considerations

For Non-Palpable Implants

• If the implant is not palpable, ultrasound localization should be performed before attempting removal
• Non-palpable implants may be located at depths ranging from 2.7 to 12mm 1
• For deeply inserted implants, the same parallel incision approach is recommended, though the incision may need to be slightly longer (up to 1cm) 2

For Difficult Removals

• For implants considered higher risk (very deep or in unusual locations), a larger incision (up to 15mm) may be required 1
• Implants located in sites other than the medial aspect of the arm are associated with longer localization times 1
• Previous failed removal attempts increase the difficulty of subsequent removals

Common Pitfalls to Avoid

• Making the incision perpendicular to the implant, which makes visualization and extraction more difficult
• Insufficient local anesthesia, leading to patient discomfort and poor cooperation
• Excessive force during extraction, which can cause implant breakage
• Inadequate visualization before grasping the implant
• Making the incision too small, limiting access and visibility

The parallel incision approach allows for the most direct access to the implant with minimal tissue disruption, leading to faster removal times and better cosmetic outcomes. This technique has been shown to be successful in removing implants in an average of 4-5 minutes, with more than 90% of cases completed in less than 10 minutes 1.