Re: Letter in response to “Neuropathy Associated with Etonogestrel Implant Insertion”

I welcome the correspondence highlighting Implanon insertion site advances, namely the avoidance of the intermuscular groove between biceps and triceps. The official Nexplanon UK on-line insertion guide currently advises insertion “8–10 cm above the medial epicondyle…to minimize the risk of neurovascular damage” [ ]. This insertion guide makes no reference to the biceps/triceps groove. The manufacturer revised the Summary of Product Characteristics in 2007, deleting reference to this groove [ , ]. The manufacturer's instruction to insert in the region 8–10 cm above, or proximal, to the medial epicondyle avoids this groove by lying posterior to it, albeit by a rather small distance. Insertion over the anteromedial aspect of biceps was recommended by Bragg et al. [ ]; however, this site will likely produce a less concealed scar. Palpating the brachial artery can be used as an anatomical marker for the neurovascular bundle, with insertion performed a suitable distance anterior or posterior to this. Nexplanon provides a redesigned applicator when compared to its predecessor Implanon; however, this does not influence choice of insertion site. Although not compulsory, it is strongly advised that healthcare professionals receive official Nexplanon training in appropriate insertion and removal techniques to avoid damage to neural and vascular structures.