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Ties - Part II, oral evaluation, frenotomy and after.

 

There’s a lot of info - so here’s a roadmap (TL/DR) for this page:

  • I start with an overall description of preparing for tie-release and choosing release providers

  • Then I discuss caring for your baby after tie-release/frenotomy - your “three jobs” (1) woundcare (2) soreness relief and (3) oral and body exercises to promote full function.

  • Those sections have many resources within, but below that are specific resources for

Okay - strap-in!

Accurate assessment and timing of release is crucial

I wrote in the Ties, Part I page how to distinguish ties from tight body/oral muscles, provided many resources to learn about ties, and discussed the idea that the timing of tie release (when needed) is very important.

If a tie-release (also called frenotomy, frenectomy and many other similarly named terms) is done too soon (baby too tight or too stressed, parents not ready for post-release wouncare (see below) and more) - the procedure may be less effective or even not work at all. If a baby only has muscular tension/asymmetry then the release is not even needed. This is why doing bodywork and oral exercises are essential first steps. Not only will these exercises aid oral/body tension and prepare the baby for a tie-release, but they also help caregivers to feel and assist the baby’s oral and body patterns (and how they are changing over time). The exercises are also fun and bonding - making the whole process of ties, which can be stressful of course, a bit easier to manage.

For this reason it’s important to not rush to a tongue-tie release - babies (and their parents!) need preparation prior to a release.

This is called “optimal timing of release”

If there are ties along with muscular tension (let’s say “embedded” within the tension), then pre-relieving muscular tension is the first step. This is also called pre-habilitation, or “pre-hab” - doing physical therapy prior to any surgery or procedure (also true for anyone who is going to have (or is trying to avoid) any type of surgery!). Bodywork and oral exercises aid tension, flexibility, strength, muscular/neurological tone, and range of motion - and together help ready babies for a better tie-evaluation/diagnosis, release procedure and healing. These exercises also give YOU time to learn more about ties, to practice oral/body exercises, to practice and plan for woundcare - all of which will be needed after the tie-release. Doing pre-hab benefits the baby and their caregivers in a multitude of ways.

If there is not time/ability to prep the baby for the frenotomy, or if the caregivers are not ready to do the woundcare after - then it may not be the right time to do the procedure. Remember - the tie release procedure, when indicated, can be very helpful - but it’s rarely a quick fix. The baby needs time to heal properly and re-learn to use their “new tongue”, and their caregivers need to be ready to help this process.

Even though tie-releases are considered a minor procedure, like all procedures/surgeries there can be risks to consider. This excellent overview by Tongue Tied Experts/Lisa Palladino does a great job of discussing the possible risks and issues that can occur.

Choosing tie-release providers

Your IBCLC or SLP will have well-vetted referrals for the best person to do the evaluation, diagnosis and frenotomy/release procedure. It is extremely important to choose a fully experienced frenotomy provider - one that understands how ties are connected to oral/body tension, why the posterior component of a tongue tie matters, if a frenulum (tongue, lip, or cheek) could benefit from release, and when it’s better to leave them untouched. And, without a doubt - a provider who performs a precise and complete release of ties.

This article discusses how to choose the correct provider - including various questions to ask them at your consultation/evaluation. It is a red-flag if a provider does not have a thorough section on ties on their site, or if the experienced IBCLC, SLPs and bodyworkers in your area do not know of them. I wrote more on choosing providers in my Ties, Part I page, and have a very specific list of providers that I refer to in my area.

Know that when you go to a release provider for an oral evaluation, many will offer the procedure the same day (if they think the baby has ties, and are ready to have the procedure). However, you can always ask for a consultation-only appointment, so you never feel rushed if you are not ready.

To give you a sense of what the release provider will look for - here is an assessment for tongue and lip ties, here is an article on buccal/cheek ties; an Instagram post showing a double buccal tie; and an Instagram post showing a buccal assessment. The best tie-release providers also include the functional assessment that has been done by the IBCLC or SLP prior to release as part of their process for diagnosis. It is a red-flag if they are not requiring you to have a complete functional assessment prior to their visit, and/or referring you for functional rehabilitation after (see more on this below).

Caring for your baby after frenotomy

If the baby has the release procedure (frenotomy) you then you have three jobs after the procedure:

1st job - woundcare (prevent re-attachment)

  • The tie-release procedure creates a diamond-shaped wound under the tongue (and a not quite diamond shape wound under the lip and cheeks).

  • The two sides of the wound touch each other when the mouth is closed. Your goal is separate the tongue from the floor of the mouth (or the lip/cheeks from the gumline) throughout the day. Doing the separation is often called “stretches”.

  • Because babies are very quick healers, this has to be done frequently throughout the day, so that the two sides of the wound don’t “sew” back together (also called “re-attachment”).

  • We want to minimize stress for the baby and for you! For that reason, woundcare should be either fast and accurate if the baby is awake, or slow and steady if the baby is asleep.

  • Woundcare/stretches are not exercises though - they are simply caring for the wound so it heals properly. However, oral/body exercises (see below) are an extension of woundcare - because movement also helps maintain a good separation between the tongue and floor of mouth (or lip/cheeks and gumline). We don’t want the baby’s mouth laying static for hours between each stretch/woundcare session. Instead, we want to use the time in between woundcare for activities that not only promote healing and better function, but also promote positive experiences for the baby and for you!

  • Below are many examples of woundcare/stretches to learn from (It is very helpful to visualize stretches and even practice them a bit prior to the tie-release - so that you are ready to do them), as well as ideas to use if you think the wound is re-attaching or healing tightly.


    2nd job - soreness relief

  • Take a moment to think about how you will help your baby with any soreness - most babies do better than you imagine they will - but it’s good to be ready just in case. Many examples of soreness relief are listed below.


3rd job - oral/body exercises to aid baby’s healing and movement
(also called Neuro-Muscular Rehabilitation (NMR))

  • The ultimate goal of a tie-release is to achieve fully functional oral/body movement and better feeding skills. (Again, why tie-release is a process and not a quick fix!)

  • This is why oral/body exercises before and after the release are so important - aiding pliability, symmetry, tone and better feeding skills (Oral exercise page and Body exercise/massage page)

  • After a tie-release, you can now compare how the baby’s oral and body motions have improved; and which skills need some help. From that comparison, we can design specific exercises (NMR) to further the baby’s progress. For example, let’s say the baby’s tongue extension has improved post-release, but not the tongue lift - we can create an exercise routine to maintain extension while also improving tongue lift.

  • Intra-oral massage (floor or mouth, cheek pockets, outer rtions of the lip, etc) is also a highly effective tool. If used as pre-hab, the baby (and parents) are ideally already finding it enjoyable. After the release, continued intra-oral massage - at first near (but not on) the wounds to maintain the enjoyment and value of the activity. Then, over time, oral massage closer and closer to the wounds can be used to accomplish a separation of the tongue/floor of mouth (or lips/gums) similar to woundcare. Ideally this blends the fun activity of oral massage with one that is often more stressful (woundcare “stretches”) - allowing woundcare to be accomplished more easily over time.

  • Intra-oral massage also helps with the next phase of healing. Starting around 2-3 weeks after a tie release a new frenulum will start to grow.    This information often surprises people! Too often, the tie-release is thought of as only removes tissue - but it’s the new functional frenulum that is the ultimate goal of this process - a new frenulum that is further back, longer and stretchier than the original one.

  • The new frenulum will be longer/taller if the diamond wound heals tall (vertically) vs. wide (horizontally). This wonderful page by Mattos Lactation and this Instagram post describe this process very well.

  • A new frenulum can grow in too tightly (especially if there is horizontal healing) - and it’s important to distinguish new-tight frenulum growth from re-attatchment. Below are ideas for dealing with tight new frenulum or re-attachement.

Post-frenotomy woundcare videos

  • Bobby Ghaheri video (baby is just post-frenotomy)

  • And another from Bobby Ghaheri with a “puppet” - also showing intra-oral massage.

  • Mikel Newman video - shows woundcare and what re-attachment might look like.

  • National Tongue Tie Centre video - the baby is asleep the entire time! They recommend stretches after feeding and on a warm/cozy mat to keep the baby sleepy. This videos also shows excellent close-up of the diamond wound and how a bit of attachment can be gently opened.

  • Sleeping Tongue Posture Hold by Michelle Emanuel.

Soreness relief ideas

If the wound is re-attaching or healing tightly

  • Talk to your functional team (IBCLC or SLP and your release provider)

  • Taller stretch such as this Deeper Stretch Video by Richard Baxter.

  • Specific rubbing/sweeping/stretcheing of the wound as shown in woudcare videos above

  • Direct pressure/massage on the new frenulum to promote flexibility/softening. A good analogy here is how people are taught to massage scars after an operation (like a c-section scar).

  • Professional bodywork to release tension in specific areas.

  • Serrapeptase, an enzyme that digest fibrin (protein in scabs and scar-tissue), can be used to help loosen up re-attachments during wound healing, or tension in a new-frenulum. Serretia is is the only brand recommended at this time.

    • A protocol has been developed for babies by Jennifer Tow (IBCLC and Myofunctional therapist) - she teaches a course for dentists, and for IBCLCs that take her oral habilitation courses. Here is a list of IBCLCs that have taken the course (including me)

    • Two videos from the Zaghi institute showing it use (on an adult) - one, and two.

  • Direct applications such as vitamin E or steroid injections (under the guidance of your tie-release provider) can aid the flexibility of the new frenulum. Here is an example of a steroid injection post-frenotomy (on an adult, but the process can be used for babies)

  • And, unfortunately sometimes babies need a 2nd release if healing goes poorly. As you can tell from everything I’ve written here, the reasons for this are multi-faceted and complicated. If you think your baby may need a 2nd release it’s crucial to work with your IBCLC or SLP and your release-provider to guide the process.

A few more resources if you are looking for more (and if you are - wow, aren’t you tired of me yet???!!!)

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