Background

In 2011 Merck Sharp & Dohme (MSD) introduced a new etonogestrel (ENG) implant, Nexplanon, with a different type of insertion technique from its predecessor, Implanon. Over subsequent years it has become clear that the problem of incorrect placement of ENG implants, which are then unsuitable for removal using standard techniques, has continued. An effective and safe technique is needed to remove such implants, particularly for women wishing to conceive.

The correct plane of insertion is 1–2 mm below the skin surface, where the implant is readily palpable and can usually be removed using the ’pop-out' technique. When insertion is deep to the subdermal layer, implants become more difficult to palpate and remove. However the term ’deep' is too limited to explain the range of depths and different degrees of difficulty encountered with removal. An implant that is deep to the subdermal layer but superficial to the biceps or triceps fascia will still usually be palpable, although where there is uncertainty of the position, then only once the exact site is clarified with ultrasound may the ability to feel it with deep palpation be appreciated.1 Most ’deep' implants that lie above muscle fascia do not need a ’needle lift' procedure as they can easily be removed with the simpler ’U' technique using ring forceps. However, once an implant is within or below the fascia it will become impalpable, even in thin women. These fascial or subfascial implants are unsuitable for removal using the standard techniques mentioned above, so most removers who are able to do so will then choose an ’open' approach.2

Why is a different approach needed?

In cases where the implant lies immediately adjacent to neurovascular structures many practitioners will decline to perform removal owing to fears that the open dissection could result in damage to these structures. Here I describe a simple alternative …