Second, nonpalpable devices are not uncommon and require radiological imaging for localization. As an adjunct, one group adopted the hook-wire tagging method used in breast tumor surgery to allow deep-lying implants to be marked prior to extraction (Nouri, 2013). If imaging fails to locate an implant, etonogestrel blood level determination can help veriy that the implant is indeed in situ. his special assay must be coordinated with the manufacturer (1-877-467-5266).
For those not currently using hormonal contraception, the etonogestrel implant is ideally inserted within 5 days of menses onset. With LNG-releasing implants, contraception is established within 24 hours if inserted within the first 7 days of the menstrual cycle (Sivin, 1997; Steiner, 2010). For transitioning methods, an implant is placed on the day of the first placebo combination oral contraceptive (COC) pill; on the day that the next depot-medroxyprogesterone injection would be due; or within 24 hours of taking the last POP (Merck, 2016a). In women certain that they are not pregnant, insertion at other times of the cycle is followed by alternative contraception for 7 days. Related to pregnancy, an implant may be inserted before discharge following delivery or abortion (Sothornwit, 2017).
With the patient lying down, her nondominant arm, forearm, and hand are outstretched on the bed with the inner aspects of each exposed upward, and the elbow is flexed. The insertion site is marked with a sterile pen 8 to 10 cm proximal to the medial condyle of the humerus. A second mark is placed 4 cm proximally and delineates the inal path of the implant. he Nexplanon is inserted using sterile technique. The area is cleansed aseptically, and a I-percent lidocaine anesthetic track is injected beneath the sin along the planned insertion path. The implant is then placed as shown in Figure 38-4. Ater placement, both
FIGURE 38-4 Nexplanon insertion. A sterile pen marks the insertion site, which is 8 to 10 cm proximal to the medial humeral condyle. A second mark is placed 4 cm proximally along the arm's long axis. The area is cleaned aseptically, and a l-percent lidocaine anesthetic track is injected along the planned insertion path. A.The insertion device is grasped at its gripper bubbles found on either side, and the needle cap is removed outward. The device can be seen within the needle bore. The needle bevel then pierces the skin at a 30-degree angle.
B. Once the complete bevel is subcutaneous, the needle is quickly angled downward to lie horizontally. C. Importantly, the skin is tented upward by the needle as the needle is slowly advanced horizontally and subdermally. D. Once the needle is completely inserted, the lever on the top of the device is pulled backward toward the operator. This retracts the needle and thereby deposits the implant. The device is then lifted away from the skin. After placement, both patient and operator should palpate the 4-cm implant.
patient and provider should palpate and identiY both ends of the 4-cm implant. To minimize bruising at the site, a pressure ban dage is created around the arm and is removed the following day.
With implant extraction, the removal site is irst cleansed with antiseptic. he proximal end of the implant is depressed with a finger to allow the distal end to bulge up toward the skin. Ater anesthetizing the skin over this bulge, the skin is incised 2 mm toward the elbow along the long axis of the arm. he proximal butt of the implant is then pushed toward this incision. Once vis ible, the distal end of the implant is grasped with a hemostat and removed. If present, supericial adhesions surrounding an implant may be dissected away with hemostat tips placed into the incision.