We would like to thank Mary Pillai et al.1 for their very useful article on non-standard implant removal that appeared in the April 2014 Journal.

We have found, in deep implant work in two centres in Lewisham and Slough, UK, that while the depth of the implant on ultrasound is important, it is also crucial to know if the device is above, below or in the muscle fascia, as a modified U-technique is unlikely to succeed unless the implant is in the subcutaneous fat. This is because ring forceps cannot usually grip an implant through the fascia.2

An audit of 94 patients referred to the Garden Clinic in Slough for difficult removals3 revealed that 29 implants were impalpable (including one Jadelle^®). One implant (an Implanon^®) was not found and the etonogestrel assay was negative so it was decided that the implant was not present. Of the 28 implants only located on scanning, 18 were above the fascia (five were removed by the direct vision method and 13 by the U-technique), two were within the fascia and eight were below the fascia (all 10 of these implants could only be removed under direct vision).

Also (and quite astonishingly) it is worth remembering another cause of missing implants: one recently reported by a Lewisham patient as being felt by her in her left arm was completely impalpable but was easily located in her right arm!