A couple of years ago, I first started to see microdermal implants in my jail patients. This is, of course, jewelry that is implanted in the skin. These have become so popular as to be almost universal. If you work in a jail or prison (or even if you have looked around at your local grocery store), you certainly have seen these. Microdermal implants can be problematic in correctional settings, because they cannot be easily removed like the older bolts and rings. Microdermal implants are imbedded in the skin, and removal requires making an incision to extract them.
But in corrections, even though it is difficult, microdermal implants often must be removed, either as a security issue or because the patient requests that they be removed. Nowadays, these implants are so common that all correctional practitioners really should know how to deal with microdermal jewelry. But most of us were never taught how to do this in our training! I certainly never learned about these in my residency training. Such a thing would have been inconceivable back then. Cutting edge fashion in those days was long hair and grungy jeans!
So I was grateful when an opportunity for education presented itself recently. A friend of mine asked me if I would remove two of her micro dermal implants and kindly consented to have the procedure photographed. Todays JailMedicine post is a photographic tutorial on how to remove microdermal implants.
In order to remove a microdermal implant, you need to know what they look like. Here is a picture of a typical microdermal implant. It has two arms that extend beneath the skin and hold it in place. Notice that one of the arms is shorter that the other. Notice also that the decorative jewel above the skin unscrews from the base. In fact, if the patient will only be incarcerated for a short time, instead of removing the implant, you could just unscrew the jewel and place it in the patient’s property.
Removing a dermal implant requires a skin incision. Though this incision will be small, it still carries a risk of bleeding, infection and scarring. Because of this, correctional patients should consent to the procedure before you begin. Can you get by with just unscrewing the jewel and leaving the implant base? How you get this consent and how you document it, I will leave to your facility’s policy.
You begin the procedure by removing unscrewing the decorative jewel and removing it (Note that the base alone without the jewel is seen as a little black dot on the skin, not very obtrusive). The next task is to palpate the base of the implant to identify the orientation of the dermal arms and especially try to identify which side the shorter arm is on. If you can, you should make your incision over the shorter arm so it can be a little smaller. Depending on how thick the skin is, this may be difficult. Like in this case! Back skin is thick, and I really couldn’t tell which side had the shorter arm. But that’s OK. It still will work out, as it did in this case.
Step Three—Prep the area.
I prefer to use 0.25% bupivicaine (Marcaine) with epinephrine. Why Marcaine? Well, they are comparable in price and Marcaine has the advantage of lasting 3-4 times longer, so the area stays numb for 12-16 hours instead of 4 hours. Why use epinephrine? The main reason to use epinephrine is that it constricts skin blood vessels so there is much less bleeding. This makes the procedure that much easier to perform. Epi also makes the anesthesia last longer—another bonus for the patient!
Step Five—Make the Incision.
The best scalpel for this procedure–by far– is a #11 blade. The #11 blade is pointed at the tip and becomes broad at the base, like a spear point which allows you to make a much smaller incision than does a #15 or even worse, a #12 blade. Place the tip of the blade at the base of the implant and stab down along the edge of the subdermal arm that you identified before. The deeper you stab, the bigger the incision. In this way, you can easily control the incision length. The cut does not have to be very big! A couple of millimeters is all you need. Note that you must hold the implant steady with forceps.
Notice that the incisions on my patient’s back are tiny. No suture was needed in this case or in most cases. I imagine that you could consider one small (6.0) suture if the site was on the patient’s face.
And you’re done! These tend to bleed a minimal amount and can be dress with a bandaid. Easy Peasy! This procedure is much easier, for example, than I&D of an abscess or removing a toenail. Correctional Practitioners should not feel intimidated by a little microdermal implant!
Mandatory disclaimer! The technique I used here is a result of my training, experience and preferences. Others may use different techniques that are just as effective. Also, my patient was young, healthy and cooperative and her implants were in an easy-to-access area. You may consider sending patients to an expert if the implant is in a potentially complicated area, like a scrotum or near the eye or if the patient has complicating health issues!