With any surgical procedure, post operative care is important to optimize healing and for the end surgical result to be as ideal as possible. This is the same for post-revision maintenance and care of the tongue and lip sites that may be revised. The items below will outline a few key points that should better explain why the post-operative care or stretches are important, how to perform the stretches and other post-revision changes that may occur.
Immediately following the procedure you may notice a diamond appearance in the area that was revised. Sometimes this diamond is under the tongue and can only be seen when you reflect the tongue up or your little one cries. The border of this area may have a slight white appearance to it, which is completely normal. The inside of the diamond may appear pink or slightly red. Bleeding from the site is extremely rare, BUT may occur during stretching or massage exercises which will be touched on later.
When your skin sustains a wound and the outer epithial layer is damaged the body wants to close that area up as fast as possible to protect against foreign bacteria. Smaller wounds or cuts will heal faster on the skin because the two pieces can connect back together and heal easier. This is called healing by primary intention. Some wounds are larger or wider and they do not heal as easy or smooth as this is referred to as healing by secondary intention. Often when you get an ulcer in your mouth or blister on your skin, the wound has to heal from the outside edge in toward the center and from the deepest part to the most superficial part. A revision of a lip or tongue heals by secondary intention, but is deeper and larger than the ulcer you may experience in your mouth. The stretching and massaging of the revision site will help keep the tissue pliable and moving while helping the collagen fibers that are forming line up flatten.
To stretch the tongue revision site: Gently lay your child on the floor or into your lap. Gently sweep your finger under your child’s tongue and with light pressure, and apply even pressure to the underside of the tongue and push the tongue back and upwards, this will help open the diamond and keep it mobile. Do not hesitate if you feel tightness, gently, but firmly run your finger from 12 O’clock to 6 O’clock and back. Move your finger back to the mid-point under the tongue and try to gently reflect it upwards and slightly backwards and hold that position. This will expose the revision site and try to hold that for 5 - 10 seconds.
To stretch the upper lip: Lay your child flat on the floor or in your lap, facing yourself. Take both thumbs or index fingers on either side of the lip, adjacent to the revision site and gently pull up and roll the upper lip up and out away from the nose and nostrils. Breast milk or formula on the finger can help keep the infant more calm and help lubricate the stretching motion. Hold that position for 5 to 10 seconds and then rub the revision site gently. Repeat this and then proceed to nurse or calm your child back down as needed.
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 stretches will take a total of 15-20 seconds each time they need to be performed.
The timing of the stretches should be spaced out as best as possible during the day. The three 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.
Performing stretches when the infant is asleep is another option as well.
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.
My recommended stretching routine is:
Day 1: Day of Procedure: 1 set
Day 2 and Day 3: 7 sets, evenly spaced through day and night
Day 4 through Day 21: 4-5 sets, Breakfast, Lunch, Dinner, Overnight
Day 21 and on: If the wound site appear virtually identical to the adjacent tissue that was not revised, you can likely stop of decrease stretches to 1 time per day for one more week. If the wound site is slower to heal due to the infant’s healing speed or the initial revision site may have been larger, continue until the wound site appears healed and matches adjacent tissue color.
The day of the revision and the following day or so after the revision you may notice your infant is somewhat fussy or irritable. I strongly advise the use of Tylenol and the appropriate dosage will be provided to you the day of the procedure based on your child’s weight. DO NOT use Motrin or Ibuprofen in any infant under 6 months of age. Staying ahead of the discomfort and being proactive with pain management is a good practice. Other methods to soothe the child can include, skin to skin contact, more frequent nursing, and a warm bath and rocking the child. If possible, try to freeze a bag of breastmilk and lay flat in the freezer. You can break pieces of the frozen breastmilk off to help soothe the revision site and help when doing the stretches.
Overall discomfort may not be evident in some children, while others will experience a mild to moderate discomfort. Feeding habits and duration of feeds may change in the first days. The first 24 hours typically is when discomfort may be noticed, but may last up to 36 - 48 hours. It is not uncommon to see changes in behavior and discomfort last into a full second or third day. Every child will respond different to treatment and need varying degrees of treatment to address their lip or tongue tie.
Tylenol is the best for pain relief. At times the infant may find “skin to skin” contact to be soothing and help if fussiness continues. Before giving any pain medicine, please refer to the medication dosing sheet I can provide at your visit. It is highly recommended to avoid Motrin or Advil in anyone under 6 months of age. Aspirin should NEVER be given to infants. Teething gels with benzocaine (typically by Orajel or Anbesol) are NOT advised in infants due to health risks, also the medicine would cause a burning sensation to the revised area.
Again, a minimal amount of bleeding may be noticed with stretching. The next day you may notice the upper lip (if it was revised) to be slightly puffy. This is caused by an inflammatory reaction within the body and typically will subside within 24-48 hours. Do not be alarmed. The diamond area that was revised will change from a pinkish-red to a white-off yellow appearance within a day typically. This is NOT an infection. The mouth will not form a typical scab that we see on our skin, but fill in with a whitish/yellowish coat. The diamond will shrink and become smaller and smaller over approximately a 2 week period, depending on severity of revision that was needed
Most wounds will typically heal on the surface in 10 to 14 days. Depending on the size of the wound, which is determined by the initial presentation of the frenulum, it may take 2-3 weeks to heal. The wound will continue to heal underneath the mucosa over the course of the following weeks.
If pain, bleeding or increased fussiness that is not controlled by Tylenol or “skin to skin” contact, try to back off pressure used or frequency and duration of stretching.
Yes, I have no reservations with the use of a pacifier after the procedure. Your best pacifier to utilize is likely a Soothie type pacifier due to the cylindrical shape. This pacifier requires more grooving and work with the tongue to hold compared to other designs. The other designs may allow for an easier ability to hold, but the child is likely close the mouth down onto the pacifier and due to the design it essential gets locked behind the jaws and is easier to stabilize.
The use of a finger is ideal as well and will provide feedback to you as a parent as to how the tongue is moving, contact it is able to keep with the finger and motion the tongue is making as the infant sucks on the finger. You can do post-procedural suck training with your bare clean finger or the Soothie pacifier and stimulate the roof of the mouth and gently pull and tug on the pacifier. As the pacifier starts to come out of the mouth, the infant should suck more vigorously and allow them to suck the pacifier back into the mouth.
Prolonged use of the pacifier is not advised though. The use of a pacifier utilizes more facial muscles and can exert an increased inward force towards the jaws, while the tongue will not exert an equal force outwards. Prolonged use through the day and excessive sucking force can be summative and cause the upper and lower jaw to narrow. The goal of the tongue is to rest on the roof of the mouth or palate and help widen and flatten the palate.
You should absolutely revisit the lactation consultant you are most comfortable with anywhere from day 2 to day 5, depending on the age of the child and how critical the nursing challenges have been leading up to the revision. Newborns, under 2-3 weeks of age, should unsure that the baby is producing enough wet diapers and if possible, rent a scale to help better assess and track the amount of milk the baby is transferring from the mother.
Some infants will benefit from adjunctive therapy to help strengthen the help better coordinate the tongues movement. The post revision period can take some time to perfect. It is like when you were learning to ride a bike for the first time and had to use training wheels. The training wheels may need to stay on for a short time for some infants and longer for other infants. The end goal is the same: to get the infant to ride the bike without training wheels (nurse efficiently and effectively without a shield or maternal help (breast compressions). Of course as you ride the bike you will find it easier each time to get on the bike and go.
Some babies will have a weaker suck and lower oral muscle tone. These babies will not necessarily improve in the first week or two post revision. You have to remember, that these infants have spent months within the uterus developing and having limited tongue mobility and have not used these muscle, hence they may be weaker. These infants still need to feed and will reflexively suck when a nipple or finger is placed within the mouth. When the tongue is weaker, the body will depend on and recruit other muscles, that typically do not participate in ideal nursing, to help extract milk. These muscles may become fatigued and flutter during the nursing session because they are being overworked. The jaw and muscle that were recruited to help with nursing will become more tense during and after nursing. These infants are overcompensating and until the underlying anatomical restriction is addressed and revised and/or the overall muscle tone and coordination of the tongue is improved, the infant will slowly improve with routine exercise and proper breastfeeding technique.
Saliva has favorable properties with healing and drooling or excess saliva may be considered normal after a revision. The baby may also swallow less often in the days following the procedure compared to before the revision. With a new range of tongue motion and relearning that needs to occur to more fully control and coordinate the tongue, swallowing may occur less.
Why is my infant spiting up more after the procedure, when this rarely occurred before?
Following the procedure milk intake from the mother may increase from prior intake levels. The infant may only be able to eat and retain a certain amount of milk in their stomach. When excessive amounts of milk are consumed, the baby may spit up extra milk.
Excessive spit up may also be a result of excessive air intake while nursing. With the new range of motion of the tongue and recoordination that needs to occur to better control the suck-swallow and breathe cycle, some air may be ingested. When the infant is burped, the ingested air may push milk out and result in more frequent spit up.
Follow up with a lactation consultant can help better determine what may be causing the new onset spit up. A weighed transfer of milk when breast feeding can help determine if the milk intake has improved and can be causing the spit up episodes. Other sources of spit up could be food sensitivities or other gastrointestinal issues that should be addressed with your pediatrician.
Once a tongue or lip is properly and fully revised a diamond shaped wound will result. In our office, a full revision, down to nearly the tongue muscle is performed to completely release the frenulum.
Think of the diamond as a baseball diamond. Typically over the 2 weeks following the revision the diamond will shrink towards the the pitcher’s mound. The wound is a 3-dimensional area that also has a depth component as well as horizontal and vertical component. Think of this as ground underneath the pitcher’s mound. Again, over the 2 weeks of typically healing, the diamond will shrink in and fill in from the deepest part to the most superficial part. The diamond will fill in and slightly constrict and tighten in the 2-3 weeks to following the revision. The body does not want to have an open wound or area that could allow any foreign bacteria or body to enter, so the healing occurs rapidly in a healthy individual. Without proper management of the wound site with stretches, the healing will occur more rapidly and constrict or tighten the area under the tongue or lip that was already released. Some scar formation and healing must occur, but the goal is to limit the density and thickness of a collagen that is formed and allow for it to be smoother and flatter once fully healed.
Some individuals will have a tendency to form thicker collagen or a denser scar and may form keloids. This is not reattachment, but healing of a wound and pulling the tissue tighter from the original margins or edges of the diamond. Keloids are genetic in nature and typical one of the parents has some history of this issue.
Stretches are extremely important in the entire process of a tongue and lip revision and need to be done properly and with the recommended frequency, or the end result may not be ideal.
If following a revision, you have improved nursing and a few weeks or months later notice a change in the baby’s behavior or your symptoms returning you may need to have the revision site reassessed. Your baby will grow and change dramatically over the first months of life and undergo major growth within the jaw, head and neck area. As the neck elongates the tongue is pulled back down into the neck and effectively shortens the tongue that remains in the mouth. Should the symptoms not resolve with a week, you should follow-up with your lactation consultant and if no improvement is seen at that point, you may need to have the area under the tongue re-addressed. If this issue is going to occur, the highest frequency of patients were those that were treated at a very young age (under 2 weeks of age), but can happen to other babies who were treated later.
If the tongue was revised it may take time for the infant to adjust to the new found range of motion. Younger children seem to adjust quicker and do not have to “re-learn” as much compared to an older infant (4+ Months old) who may have become accustomed to the restricted tongue movement. It is highly recommended you have your lactation consultant help with re-learning and possible repositioning to help with breastfeeding. Improvement is rarely an instant phenomenon, it will take time for your child to learn how to manipulate the tongue and coordinate sucking. The tongue is a large muscle and the frenum is a connective piece of tissue. The tongue may have been an accessory muscle and other muscles of the face that typically are not used in sucking may have been primary muscles. With time the tongue will hopefully predominate the function of sucking and make breastfeeding more efficient and comfortable.
As the tongue and accessory muscles learn to work together and in harmony you should notice a difference in the overall nursing. It may take a 3 weeks to fully get adjusted. If sucking is still fairly uncoordinated and problematic after 3 weeks, you should be in touch with your lactation consultant to find exercises to use to work on getting into a better routine and always feel free to contact me again.
If the lip was revised an almost instant improvement in latch, seal and decrease in leaking should be noticed. The lip, much like the tongue, needs to be guided to flip out to make a seal. The lip will at times need to be flanged out to make a better seal, but in time should be more natural for the child and they should be able to adjust in a short period of time with some guidance.