What is the procedure for removing Nexplanon (etonogestrel implant)

Nexplanon Removal Procedure

The Nexplanon (etonogestrel implant) removal procedure is a straightforward office-based procedure that typically takes less than 5 minutes to complete through a small 2-3mm incision using ring forceps when performed by a trained healthcare provider. 1, 2

Pre-Procedure Preparation

• Verify the location of the implant by palpation
• If the implant is not palpable:
  • Ultrasound should be used to determine depth (implants can be located 2.7-12mm deep) 2
  • For radiopaque Nexplanon, real-time fluoroscopic-guided localization can be used 3
  • For non-radiopaque implants, soft tissue x-ray (AP, lateral and internal oblique; 45-55 kVP) can help locate the implant 4

Equipment Needed

• Sterile gloves
• Antiseptic solution
• Local anesthetic (1% lidocaine, 6-8 mL)
• Sterile drape
• Scalpel with small blade
• Ring forceps
• Adhesive bandage or sterile dressing
• Sterile gauze

Standard Removal Procedure

1. Patient Positioning

   • Position the patient supine with the arm containing the implant flexed at the elbow and externally rotated

2. Implant Localization

   • Palpate to locate the implant
   • Mark the distal and proximal ends of the implant on the skin

3. Skin Preparation

   • Clean the removal site with antiseptic solution
   • Apply sterile drapes to create a sterile field

4. Anesthesia

   • Inject 1-2 mL of 1% lidocaine beneath the distal end of the implant
   • Ensure adequate anesthesia before proceeding

5. Incision and Removal

   • Make a 2-3mm incision at the distal end of the implant 2
   • Use gentle pressure to push the proximal end of the implant toward the incision
   • When the tip becomes visible, grasp it with ring forceps
   • Remove the implant gently through the incision

6. Wound Closure

   • For standard removals, suturing is typically not necessary 4
   • Apply pressure to ensure hemostasis
   • Apply adhesive bandage or sterile dressing

Special Considerations for Deep or Non-Palpable Implants

• For deeply inserted implants (>5mm depth), consider referral to a provider experienced in complex removals 2
• For non-palpable implants:
  • Use ultrasound guidance to locate the implant before attempting removal
  • Consider a larger incision (up to 15mm) for difficult cases 2
  • In cases of deep muscle tissue location, surgical removal may be required 5

Post-Procedure Care

• Apply pressure dressing for 24 hours
• Instruct patient on proper wound care:
  • Apply sterile dressing daily with local disinfection until granulation occurs (usually 1-7 days) 1
  • Keep the area clean and dry
  • Avoid heavy lifting or strenuous activity with that arm for 24 hours

Potential Complications

• The most common challenge during removal is encasement of the implant within fibrotic tissue 5
• Other potential complications include:
  • Pins and needles/numbness in the arm/hand/fingers 5
  • Infection at the removal site
  • Scarring
  • Rarely, nerve injury during removal 6

Follow-up

• If a new implant is desired, it can be inserted immediately through the same incision
• If no new implant is inserted, fertility returns rapidly after removal 7
• Advise patients to use alternative contraception if pregnancy prevention is desired

Referral Criteria

Consider referral to specialized centers for removal of deep implants when:

• The implant is not palpable and cannot be located by ultrasound
• Previous failed removal attempts
• Implant located in unusual positions (not in medial aspect of arm)
• Implant located deeper than 5mm 2