The Importance of Active Wound Management Following Frenotomy

One of the more common discussion threads surrounding tongue/lip tie division is the topic of wound reattachment, where dyads exhibit brief windows of symptom resolution only to reverse their progress and return to the original problems with breastfeeding. This post will explain the principles of a complete tongue/lip release, the biology of wound healing, and the necessity for actively managing a wound to prevent scarring.

Frenotomy Wounds

An appropriate procedure for the lip or tongue will result in a complete release of tension caused by the inappropriately tight fibrous band. The best way to know if a proper release has been done is to look at the shape of the wound. For lingual frenotomies, there must be a diamond-shaped wound for the release to be complete. If there is no diamond-shaped wound, then the procedure hasn't fully released the tension. For the upper lip, complete laxity of the central lip should be seen and the tie should be completely lifted off of the gumline. If only a small nick in the lip tie or tongue tie is made, there will be little to no chance of improvement because the wound itself is small. Along the same lines, if the initial procedure was incomplete and scar tissue forms, the wound did not “reattach” - it was just incompletely opened. In contrast, a fully opened wound will pathologically reattach if active wound management isn’t practiced. This pathologic reattachment is different than the typical attachment we see when the tongue or lip heal normally. What we are aiming for is a band that is more flexible and forgiving than what was there prior to the procedure.                            

This sketch of the release of a lip tie shows the result of proper wound management, where a finger is gently run under the lip to separate the lip from the gumline, versus poor wound management, where too much of the lip is allowed to readhere to the gumline. Remember, if the initial release was inadequate, then you would never have achieved the good mobility in the first place, so it can mimic the reattached lip.

The tongue tie wound is more complex. First, just snipping an anterior frenulum does little to improve tongue function for breastfeeding purposes. There is always a posterior, submucosal component of the tongue tie that needs to be released. If the procedure stops short and only the anterior part of the tie is released, no open wound under the tongue results. There must be a diamond-shaped wound in order to have a full release of a tongue tie. After an incomplete procedure, stretches are irrelevant because the size of the wound created is minimal, so it will heal with minimal scarring.  The problem in this scenario is that the tension of the posterior tongue tie is still present and function doesn’t improve. What we want is a procedure that fully releases the tension and doesn’t reattach. This can only be achieved by actively stretching the wound. My protocol for that is here.

Principles of Wound Healing

While some of the principles of wound healing inside the mouth also apply to wounds on the skin, there are certain characteristics that are unique to oral wounds. The best description of these characteristics is in the book “Oral Wound Healing” by Hannu Larjava (2012). When a wound is created, it will undergo specific, predictable changes in an attempt to close that wound. Within 24 hours of wound creation, the edges of the wound begin to migrate towards the center of the wound so that the edges can try and eventually zipper together with a mucous membrane covering. This migration is facilitated by a scaffolding that forms over the wound (this is the white/yellow color we see as an oral wound is healing).  At the same time, granulation tissue begins to fill the wound. Granulation tissue serves to reform the connective tissue that gives the new wound strength. It does this by migrating new blood vessels into the area and forming a matrix of fibers that are the precursors to scar formation. It can take months for the mature wound to finally form. During this time, wound contraction occurs as the scar fibers organize.

How does this apply to tongue tie and lip tie? When a provider creates a wound in the mouth to try and release a tethered band, the mouth will try close that wound. In the context of tongue tie and lip tie, we want those wounds to heal in an open conformation rather than closed back together. It is also important to translate this expected progression of wound healing into what should visibly happen to the wounds. Lip releases heal extremely well and aren’t typically subjected to what happens under the tongue. It is important, however, to understand that there will be a new band connecting the lip to the gumline - that's part of normal lip healing. For the tongue, the first 5-7 days following a frenotomy demonstrate a soft wound with good mobility. As time goes on, the diamond under the tongue will start to contract and get firm. This is most prevalent between days 10-21 after a procedure. The scar tissue developing within the diamond will ultimately loosen again after day 21, and can take months to fully soften and mature.

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Horizontal vs Vertical Healing

Remember, once an open wound is created in the mouth, the body will try to close the wound and contract toward its center. The end result is that the lip will try to stick back down to the gumline and the tongue will try to stick back down to the floor of mouth. The trick to achieving optimal results is to try and guide the tissue, through proper stretches, to heal in a way that maximizes vertical movement. This vertical movement is important for upward flanging of the lip and more importantly, upward movement of the tongue towards the palate to form the seal necessary for vacuum generation.

Tools and Techniques

To my knowledge, there haven’t been any published studies that demonstrate superior wound healing outcomes with a particular surgical technique or instrument. Some laser studies show potential benefits when studied in the lab or in animal models, but so far no human studies exist that demonstrate a difference. What is important to recognize is that the tool being used for the procedure really doesn’t matter. What matters is the depth of the release - an adequate release resulting in a diamond-shaped wound needs stretching regardless of the instrument that was used to create the wound.

Why do some wounds behave poorly and result in inflexible scar formation? There are many potential reasons:

1. The release was inadequate from the beginning so scar tissue forms on top of already immobile tissue    
2. Poor adherence to wound stretching protocols
3. Poor surgical technique - cutting too deep (muscle damage) and stimulating a more rigorous inflammatory response
4. Delivery of too much energy to the wound, either by the inadequately trained laser provider who turns a 45 second procedure in a much longer exposure to laser energy or laser settings that are inappropriate
5. Inherent scar forming tendencies of the patient

While the success of the procedure doesn’t come from the tool used, my experience has been that the use of electrocautery causes more collateral damage (when compared to laser or scissors), resulting in more scarring. There are always exceptions to this rule, so it is important to know how to choose your provider appropriately.

The most successful approach to tongue/lip tie revision includes:

1. The IBCLC, who helps to establish better latch mechanics and positioning in addition to improving sucking skills
2. A therapist to help resolve muscle tension which can inhibit both the latch and proper wound healing
3. The provider, who should create a proper wound and manage the healing in a way to maximize the mobility of the lip and/or tongue 

This multidisciplinary approach is the key to successful rehabilitation from a problematic nursing relationship.

How to Take Appropriate Pictures for Tongue Tie or Lip Tie Evaluation

This post has one basic goal: to teach you how to take appropriate pictures of the tongue or lip to help others evaluate your baby from a distance.

1) taking good pictures requires 2 people. A tongue selfie does no one any good. One person lifts the lip or the tongue and the other snaps the picture.

2) get good illumination - a decent LED headlight now costs less than $20.

3) Proper positioning - the lip and the tongue should move up for normal breastfeeding. Getting your fingers under the lip or under the tongue is important for testing if you can easily pick the tongue up. Position yourself from above so that the baby's feet are moving away from you.

4) Here’s a video on how to elevate the lip or the tongue: https://vimeo.com/

5) For the person taking the picture, make sure you position yourself so you can bring the entire frenulum in view. One trick is to have the focus already set by focusing on the mouth before you do the elevation. On iPhones (and possibly Android phones), holding your finger on the desired area of focus for several seconds will result in a locked “autofocus/autoexposure”, so that it won’t try to refocus as the baby moves. Another trick is to just hold the shutter down and take a rapid burst of photos to see if you can find a suitable picture. Along similar lines, you could take a video and then choose a screen shot later.

Tongue tie vs lip tie: which is more to blame?

As awareness about the impact of tongue tie and lip tie on breast-feeding has become more widespread, more and more people are having questions about how to best evaluate babies with breastfeeding problems. Many people focus on lip tie as the major problem with breastfeeding. I receive many pictures of babies' lips from parents who are wondering whether a simple lip revision will take care of their problems.

Why is there such a focus on the lip? I have several theories:

1) It's an easy structure to evaluate.

2) Many parents and practitioners are confused about the difference between a normal labial frenulum and a lip tie. I've written about that previously.  

3) The procedure and the recovery are relatively easy. The stretching exercises for the lip are well-tolerated and the reattachment rate is extremely low. 

Wouldn't it be great if such a simple lip procedure took care of so many problems? I do think that the upper lip plays a role in normal breast-feeding. With a lip tie, the child has difficulties flanging the upper lip, and this can cause muscular tension that can make opening the mouth widely very difficult. The result is a shallow latch, a small mouth (baby can't open widely), nipple pain and nipple trauma. In my experience, if a baby comes to my office with breastfeeding problems and has a tie, 99% of the time that child will have a tongue tie. They may also have a lip tie (about 50-60% of the time) accompanying the tongue tie but isolated lip tie is very uncommon - it makes up less than 1% of the babies that I treat. Those few babies have normal tongue function; the lip restriction is the only obstacle to achieving a normal latch. For most babies, however, a tongue restriction is the problem.

Why do I think that the tongue is usually to blame?

1) The tongue is the active muscle in breastfeeding. It is responsible for the creation of negative pressure that is necessary to nurse normally. The lip, on the other hand, is a relatively static/passive component of normal breastfeeding. It can get in the way, but a normal lip doesn't guarantee normal feeding. A normal tongue, on the other hand, is much more predictive of normal breastfeeding. 

2) Almost every published paper demonstrating the benefit of frenotomy on breastfeeding included patients who only had a tongue tie release. Most ignored the lip. Despite ignoring the lip, the available evidence shows that lingual frenotomy alone was beneficial. 

3) When the tongue is tethered, it can affect the lip's function. If the tongue does not form the peristaltic wave necessary for vacuum generation, the baby can forcefully try to suck the breast in. This can cause the upper (and lower) lip to get sucked in, again causing the mouth to stay closed. This can mimic a lip tie because many people equate a rolled-in lip with a lip tie when it's really the tongue's fault. Think of the lip motions necessary to use a straw: the lips must purse with strength to hold suction. In people with facial paralysis (like with Bell's Palsy or who have suffered a stroke), they are unable to purse the lips on the affected side and the suction is weak and liquid can dribble out. How does this relate to a baby? If a baby's tongue isn't working appropriately, they will often purse their lips to hold on tightly to the breast - this can result in the upper (and lower) lip turning in, even if there's no true lip tie.

Remember, most of the symptoms common to tied children are caused by the tongue's inability to move up: clicking, poor suction, poor breast drainage, leaking out the sides of the mouth, slipping to the end of the breast, popping on and off the breast, poor weight gain, falling asleep prematurely only to wake up hungry later, reflux/colic symptoms and pain/nipple trauma. The one major overlapping symptom set with isolated lip ties occurs in moms who have lots of pain and nipple damage without the other tongue symptoms. If the tongue has good superior movement in the mouth, then I will treat the upper lip alone and wait to determine if something else needs to be done.

If a practitioner focuses on a lip tie without evaluating the tongue or determines that the tongue is "normal" even in the presence of the aforementioned symptoms of tongue restriction, it may be an indication of inadequate education or experience in diagnosing or treating tongue ties. In my mind, the tongue should be the first place a practitioner should look before even worrying about the lip. Quite often, I will only treat the tongue if I'm not sure of the impact of the lip on the breastfeeding relationship. In those instances, I usually never see those babies back because the tongue release alone is sufficient to improve that relationship.

Breastfeeding Problems Can Affect the Emotional Health of Mom and Baby

As an ENT surgeon, my initial exposure to breastfeeding medicine focused on the technical aspects of frenotomy as it relates to breastfeeding problems. Early on, I would see babies for a specific purpose and beyond that, I relied on my community lactation consultants to begin the task of improving breastfeeding quality. However, as a father of tongue-tied children and as a husband to an amazing woman who suffered through breastfeeding our first child, I have always been aware of the toll that abnormal breastfeeding takes on a mom (and family). In this post, I want to look at some of the factors affected by breastfeeding that don’t necessarily focus on infant nutrition and latch quality. Some of what I will present will have references supporting my ideas, but there are also ideas I have about the impact of breastfeeding abnormalities that haven’t fully been studied.

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Emotional health for mom - I previously wrote about the importance of mom’s symptoms when considering whether a frenotomy is warranted. When a baby is having difficulty breastfeeding, mom’s stress is visible and almost palpable. Mom has an inherent instinct to nourish her child, and a disruption in that desire can have profound psychological impacts. An extremely important study tracking these impacts was published this year by Cristina Borra and colleagues. In this study, the rates of maternal postpartum depression (PPD) were measured in relation to breastfeeding success. The moms with the lowest rate of PPD were the moms who intended to breastfeed and successfully did so. The moms with the highest rate of PPD were the moms who intended to breastfeed but didn’t or couldn’t. Their risk of PPD was double that of the control group. That’s an alarming number that we cannot ignore. A similar study looks at what happens to breastfeeding when a mom has a diagnosis of PPD. Dr Stuebe and colleagues found that in instances of disrupted lactation, the median duration of breastfeeding was 1.2 months. The median duration of breastfeeding in those without disrupted lactation was 7 months. In the article, she also found that moms with a diagnosis of PPD had a higher incidence of disrupted lactation. The final article is, in my opinion, the most fascinating. While it is an animal study, Dr Hinde and colleagues examined rhesus monkey mother-baby dyads and measured cortisol levels in the mommy’s milk. They then demonstrated that the monkeys with high cortisol levels in their breastmilk had babies that were “nervous” and babies exposed to low cortisol breastmilk were more “confident”. Cortisol levels are often high in those undergoing some sort of physical or psychological trouble, so understanding the impact of cortisol is of particular interest to me. The cause of high cortisol levels and the downstream effects of these cortisol levels is very complex, and further information on the topic is found here and here. It's important to recognize that the cortisol implications regarding breastfeeding are still not completely clear, so more research is necessary.

Emotional health for baby - From a biological perspective, one of the most basic human instincts is the need to breastfeed. You may have seen a newborn crawl up a mother’s chest and latch on the breast without assistance. It’s an innate function for babies. When breastfeeding is disrupted, we know how it can affect how the baby feeds, but we don’t have data to show how much the baby suffers when this basic functional need is disrupted. One very interesting paper looking at how baby stress is measured was published in 2012 that studied infant and mom stress levels when they tried a self-settling sleep training program (like Cry It Out). What the paper found was when the mom and baby were actively struggling through the training program, their cortisol levels (an easily measurable hormone) were both very high. Once the baby was “trained” and mom moved into her own bedroom, her cortisol levels normalized, but the baby’s levels remained elevated even without signs of distress (apparently “successful” training). How does this relate to breastfeeding? I maintain that babies who have difficulty with breastfeeding are actively in distress, similar to the abandoned baby. A basic human function (like parental proximity during sleep OR breastfeeding easily) becomes disrupted, and cortisol levels can rise. At some point, we may be able to measure that. I routinely hear stories where moms email me shortly after a frenotomy and tell me that they “have a whole new baby”. These babies are often calmer, sleep better, and exhibit less body tension and just seem relaxed and happy.

It’s time that medical professionals start to look at breastfeeding as an important developmental process rather than a stair step to getting a baby to grow physically. The medical community is very good at measuring physical attributes - growth curves and physical milestones are part of well child visits. We need to focus on the neurologic and psychiatric well being of infants in addition to their moms. Our current system is failing the dyad from the emotional aspect, and we need to examine what happens as a result of that failure.