What are the recommended materials and procedure for Nexplanon (etonogestrel implant) removal?

Nexplanon Removal: Materials and Procedure

Nexplanon removal is a straightforward office-based procedure that requires specific materials and techniques to ensure safe and effective extraction of the implant. 1

Required Materials for Nexplanon Removal

• Sterile gloves
• Antiseptic solution for skin preparation
• Local anesthetic (1-2% lidocaine)
• Sterile drapes
• Scalpel with small blade (#11 blade)
• Mosquito forceps or ring forceps
• Sterile gauze
• Adhesive bandage or sterile dressing
• Sterile marker (to mark implant location)

Procedure for Removal

Pre-Procedure Assessment

1. Confirm implant location: Palpate the arm to locate the implant before beginning the procedure
2. For non-palpable implants: Use ultrasound to locate the implant before attempting removal 2
   • Non-palpable implants may be located at depths ranging from 2.7mm to 12mm 2
   • Consider referral to a specialized center for deep implants (>5mm depth) 2

Anesthesia Options

1. Traditional local anesthesia:

   • Inject 1-2ml of 1% lidocaine beneath the distal end of the implant

2. Alternative needle-free anesthesia:

   • Jet injector devices (like MadaJet XL®) can be used
   • May reduce pain perception during anesthesia administration 3
   • Particularly useful for patients with needle phobia

Removal Technique

1. Position the patient: Have the patient lie on their back with the arm flexed at the elbow and externally rotated

2. Prepare the site:

   • Clean the removal site with antiseptic solution
   • Apply sterile drapes around the area

3. Administer anesthesia:

   • Apply local anesthetic under the distal end of the implant
   • Wait 1-2 minutes for anesthesia to take effect

4. Make the incision:

   • Make a small 2-3mm incision at the distal end of the implant 2
   • For standard removals, a small incision is sufficient
   • For deep or difficult removals, a larger incision (up to 15mm) may be necessary 2

5. Extract the implant:

   • Push the proximal end of the implant toward the incision
   • When the distal end becomes visible, grasp it with forceps
   • Remove the implant gently through the incision
   • Average removal time is 4-5 minutes from incision to complete extraction 2

6. Confirm complete removal:

   • Verify the entire 4cm implant has been removed
   • Nexplanon contains barium sulfate, making it visible on X-ray if confirmation is needed 4

7. Close and dress the wound:

   • Apply pressure to ensure hemostasis
   • Close with adhesive strips if needed
   • Apply sterile dressing

Special Considerations

Difficult Removals

• Deep implants: Implants located >5mm deep may require referral to specialists 2
• Non-palpable implants: Require ultrasound localization before removal
• Common challenges: Encasement of the implant in fibrotic tissue is the most common difficulty reported during removal 5
• Success rate: Even with challenging removals, the success rate is extremely high when performed by trained clinicians 5

Complications and Management

• Rare complications:

  • Nerve injury (transient)
  • Scarring
  • Infection
  • Allergic reactions to barium sulfate (extremely rare) 4

• Post-removal care:

  • Keep the site clean and dry for 24 hours
  • Avoid heavy lifting or strenuous activity with the affected arm for 24 hours
  • Return if signs of infection develop (redness, swelling, increased pain)

Provider Training Requirements

All healthcare providers must complete specific training on Nexplanon before performing insertions or removals 1. This training ensures proper technique and minimizes complications.

Follow-up Considerations

• Fertility returns rapidly after implant removal 1
• If continued contraception is desired, a new implant can be inserted through the same incision or alternative contraception should be provided immediately

Remember that while complications are rare with Nexplanon removal, they can occur. Having the proper equipment, training, and technique significantly reduces the risk of complications.