# Nexplanon Removal

## Overview

This module describes how to remove a Nexplanon contraceptive implant.

## Indications

1. Patient request

2. After 3 years of use

## Contraindications

1. Impalpable implant (see Troubleshooting)

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“You are ready for the removal of your Nexplanon implant. This is a short and simple procedure with minimal discomfort.”

### What can my patient expect?

“I will give you an injection for pain first. I will make a small cut where the implant is, and then I’ll pull it out with tweezers.”

### What is my patient’s role?

“Keep still with your hand behind your head while I remove the implant. Fearing blood or needles is normal, but tell me if you have fainted from it. Let me know if you have any pain.”

## Preparation

Prepare a trolley with equipment.

### Documentation

1. Patient notes

### Equipment

1. Sterile gloves

2. Alcohol-based hand rub

3. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

4. Skin disinfectant
   Skin disinfectant

   Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another.

5. Swabs/cotton balls

6. Sterile suture pack

7. Scalpel blade

8. 3 ml syringe

9. Blunt fill needle & smallest gauge needle available

10. Lignocaine

11. Alcohol swab

12. Transparent film dressing and gauze

## Site & Positioning

Position the patient with their arm (containing the implant) flexed, and the hand behind their head. Palpate the arm to locate the extraction site, usually 8-10 cm proximal to the medial epicondyle and 3-5 cm inferior, overlying the triceps. On depressing the proximal end of the implant, the distal end should pop up under the skin.

## Procedure

Follow medical asepsis with sterile gloves.

1. Perform hand hygiene.

2. Draw up 2 ml lignocaine and anaesthetise the site.

3. Open the sterile pack and create a sterile field. Pour disinfectant into the well. Open the scalpel blade onto the field.

4. Perform hand hygiene and don sterile gloves.

5. Clean
   Clean

   Use circular motions from the centre outwards.

   and drape the site.

6. Depress the proximal end of the implant so that the distal end becomes visible under the skin.

7. Make a small, longitudinal

   incision
   incision

   Be careful not to cut into the implant.

   at the distal end of the implant.

8. The tip of the implant should pop out. Otherwise, gently push it towards the incision until it becomes visible. You may need to bluntly dissect adherent tissue until the tip becomes visible.

9. Grip the tip with mosquito forceps and extract the implant.

10. Confirm that the entire 4 cm rod has been removed intact.

11. Apply a gauze pad and transparent film dressing.

12. Dispose of medical waste safely.

13. Document the completion of the procedure.

## Troubleshooting

I can’t palpate the implant OR I can’t remove it.

Stop and refer the patient to a provider experienced in difficult removals.

After removal, I want to insert a second Nexplanon.

You can do this through the same incision.

I suspect I didn’t get the entire implant out.

These implants can sometimes break, resulting in incomplete removal. Refer the patient to a provider experienced in difficult removals.

## Risks

1. Bruising, minor bleeding, local pain and irritation

2. Scarring

3. Abscess formation or local infection

4. Sharps injury to healthcare personnel

## References

1. Nexplanon Prescribing Information. Organon USA LLC. 2021.