Figure 1 and 2: This shows two different tongues that were previously revised, but not completely revised. Notice the vertical white band or frenulum and webbing at the bottom of the frenulum.
Most, if not all, hospitals and medical providers in the greater Philadelphia area will use a scissor to revise the frenulum. The scissor will typically address the more anterior or front portion of the frenulum and provide some added mobility and motion to the tongue. In some cases, this initial revision will enable the child to nurse more effectively and cause less trauma to the mother. Within a few days nursing should improve and that degree of revision was sufficient for that dyad. In other cases, you may be advised through the guidance of your primary care provider or lactation consultant to look into a second revision. This results because the original release did not fully resolve the deeper or more posterior portion of the frenulum and continues to restrict the tongues mobility. During the second revision, the remaining frenulum that is under tongue and more submucosally hidden is addressed and may not be easy for you as a parent to see, but can be felt with a finger more easily. If you push straight back on the frenulum under the tongue, it may feel like a thicker guitar string or piano wire.
In some instances, depending on how poorly the tongue or lip tie initially are functioning, you may notice an instant improvement after the procedure. This improvement can be sustained indefinitely, have slight regression as the infant heals and relearns how to use the tongue or go back and forth over the first two weeks.
Other variations of tongue and lip ties will require patience, a relearning period for the infant, suck training and follow up with your lactation consultant or other providers to help facilitate the best overall outcome possible. You have to remember the tongue has had restricted movement and once you allow for an increased range of motion the tongue needs to learn how to adapt. The infant who is treated earlier in life will typically improve at a faster rate versus the infant that is revised after a few months of age. This occurs because the very young infant has less muscle memory and the mechanism used for feeding can be reprogrammed easier. The infant will also play a key factor in to how quick they are able to adjust, relearn and adapt to the newly revised tongue and/or lip. I encourage all patients to follow-up with their lactation consultants a few days post procedure to help work through new latching challenges and retraining.
Again, THIS IS NOT A QUICK FIX! The purpose of this procedure is to allow for an increased range of mobility and motion of the entire tongue. In theory, the increased motion and function will improve efficient and sustainable nursing or feeding. Many other variables can exist with the procedure and the entire birth history and both symptoms of the mother and child assessed to gauge the likelihood of overall success or improvement. Each dyad is unique and in a different starting place at time of revision and some have minimal obstacles to overcome, while others have multiple.
After a thorough review of the mother’s feeding history and infant’s feeding history, birth and medical history the infant will be examined. After a full evaluation and discussing treatment options, a signed consent is obtained from the parent and the procedure can proceed. The infant is taken into a treatment room with the provider and an assistant. The parents will wait in the exam room and review post-operative guidelines and instructions that they are given at the appointment.
The infant will be swaddled in the treatment room and protective eyewear placed on the infant, provider and assistant in the room. Once all eyewear is in place, the laser is turned on. The infant’s tongue is gently elevated with a small surgical tool called a groove tongue director. It allows for the tongue to be safely elevated and isolation of the frenulum under the tongue. The assistant will help stabilize the infant and maintain the swaddle during the procedure. The type of laser we use is a CO2 or carbon dioxide laser and does not need to come into contact with the frenulum. The laser is able to precisely and quickly release the excessive or restrictive tissue under the tongue. The entire procedure to release the tongue will last about 10 to 15 seconds.
Some infants will benefit from the release of the upper lip to allow for a wider gape and an improved seal. When revising the upper lip, we grasp the upper lip and gently roll it up towards the nose to reveal the upper lip frenulum. Again, the laser does not need to touch the tissue, and the release of the frenulum from the upper jaw to allow for an improved range of motion of the upper lip. This procedure will typically take another 10 seconds.
We may utilize an injectable lidocaine solution into the older patients, but rarely use any form of local for infants under 6 months of age. This can be discussed at the consult as to why we do not use local or topical if you have questions.
Post procedural bleeding is typically very rare, but may occur and easily managed with light pressure.
During the procedure, the infant will likely cry and be unsettled. Some of the unsettled behavior is due to having the grooved tongue director and a finger in their mouth that helps isolate the frenulum. When the laser comes into contact with the tissue it will cause minor to moderate discomfort of that precise area, but only last a few seconds as the frenulum is released. Once the procedure is complete, a cool, wet piece of gauze is wiped over the revision site to clean and cool the area.
Immediately following the procedure, the infant is returned to the parent in the exam room and the post-operative care and stretching instructions are given to the parent and thoroughly reviewed. One of the parents will need to physically do the stretches in front of the provider to ensure they are relatively comfortable with them. Once the stretching exercises have been reviewed the mother may nurse the child privately.
Some infants will be able to nurse immediately after the procedure and have dramatic improvement in their ability to feed. At times maternal pain completely resolves, ability to make a vacuum instantly improves and overall feeding behaviors change immediately following revision. A majority of infants will have subtle improvement at first and need time to unlearn bad habits and to relearn how to effectively nurse. Many of these infants were depending on facial muscle usage to compensate for the minimal tongue efforts during nursing. Each infant will present with unique symptoms and behaviors. Infants with a very disorganized suck pattern may take longer to relearn how to coordinate and learn how to nurse. Some infants can take 2 or more weeks to relearn and improve. You need to be patience with this entire process and procedure and be able to see the bigger picture and not necessarily look for instant gratification.
The day or two following the procedure your infant may be more fussy and irritable then normal. These first few days will require frequent stretching exercises that the parent needs to perform. These stretches will likely be the most challenging aspect of the entire experience and the infant typically will not care for these to be done.
The timing of the stretches should be spaced out as best as possible during the day. The two best suggestions for doing the stretches are listed below:
It is suggested to feed from one breast and then burp the infant and perform the stretches at that time. The infant may become upset, but then can be nursed on the other side to help calm them back down. If the baby is only bottle fed, stop halfway through the bottle and perform the stretches to allow for them to calm down again.
If stretching during or around feeding times creates an issue, try to do them when you change the diaper.
The stretching exercises will be reviewed in person with you once the revision is complete and the frequency of the stretches reviewed. It is recommended to stretch for a full two weeks following the revision, but a third week may be needed if not fully healed.