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

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Table of Contents for all blog posts

Accurate assessment and timing of release
is very important

I wrote in the Ties, Part I page how to distinguish ties from tight body/oral muscles, and provide many resrources to learn more about the topic of ties, as well as the idea that the timing of tie release, when needed, is very important.

If muscular/body tension, body asymmetry or nervous system function are the root problem, then bodywork and oral exercises should improve feeding and oral function without a tie-release.

If a baby has ties but also has tight/asymmetric muscles, then prepping for the release is crucial - because if a tie-release (frenotomy) is done too soon it may be less effective than hoped for, or even not work at all. And, because you can start to enjoy the process of doing these exercises - which not only help you to get to know the baby’s oral and body patterns (and how they are changing over time), but also help you and the baby to get used to the idea that these exercises are fun and bonding - which can help make the woundcare (more on that below) easier to do.

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

This is called “optimal timing of release”

If there are ties along with (or “under”) the muscular tension, then pre-relieving the muscular tension first is the first step. This is “pre-hab” - doing physical therapy prior to any surgery or procedure (for example - if you were going to have knee surgery, your physician would want you to have PT before (and after as well)). Bodywork and oral exercises “pre-loosen” the baby and get them ready for the evaluation of ties - improving the diagnosis, the tie-release procedure (frenotomy), and healing. Bodywork and oral exercises help prepare the baby physically and neurologically for a release - and help them get used to the oral exercises and post-frenotomy woundcare/stretches that need to be done after the procedure (more on that below).

This time also give YOU - the person who will be taking care of the baby after a tie-release - time to learn more about this topic, time to practice oral/body exercises, to practice (or visualize) the stretches/woundcare that need to be done after a tie-release procedure (again, more on that below), and thinking about how you will help the baby with soreness-relief after the procedure.

If there is not time/ability to help the baby with post-frenotomy care, 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 the caregivers need to be ready to help them. And, while 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 (most of which are when the people on your care team are not skilled enough, but there are other things to consider)

The oral evaluation and release providers

If it’s likely that your baby has ties, your IBCLC or SLP will have well-vetted referrals who do the oral examination to rule in/out ties, and also do the frenotomy procedure (if needed). It is extremely important to choose a fully experienced frenotomy provider - one that understands how ties/Tethered Oral Tissues are connected to oral/body tension, why the posterior component of a tongue tie matters, who assesses which frenulum (tongue, lip, cheek) could benefit from release (and which are better left untouched!), and - of course - one will do a precise and complete release of any ties. It is a red-flag if a provider does not have a very thorough section on ties on their site, for example. It’s also a red-flag if experienced IBCLC, SLPs and bodyworkers do not know of a provider. I write more choosing providers in my Ties, Part I page, and have a very specific list of providers that I refer to.

The tie-release provider will do the following physical assessments, and rely on the functional and physical assessments that should be done first by your IBCLC or SLP (again, the functional assessment is the crucial first step - do not go straight to a release provider before doing this!).

Finally when you go to a release provider for an oral evaluation, please know that while most tie-release providers offer a same day procedure, they should also offer consultation-only appointments. It is important to know if you are going there to get their assessment and then go home after to consider things - or if you are ready to go on to having the procedure done.

This article discusses how to choose the correct provider - questions to ask about their experience, how they help the baby recover, how they support you, the tool they use, if they use numbing (and what type they use), if they will let you stay in the room during the procedure, and more.

Caring for baby after a frenotomy

If the baby has the release procedure (frenotomy) you have done the research and pre-hab ahead of time (see above) - and then you have two jobs after the procedure:

1st job - woundcare/prevent re-attachment

  • There is a small diamond-shaped wound created by a proper and complete tie release.

    • Here are some photos series to look at - one photo series by Paul Bahn, and this info page and photo series by Bobby Ghaheri - both show the progression of healing. Take a moment to look at these so you have a sense of what you will see post-procedure.

    • Because the baby is so good at healing, and because the two sides of the diamond are touching each other when the mouth is closed - the baby’s healing will want to “sew” the two sides of the diamond back together, causing them to “re-attach” during the healing process - Your first job is to prevent re-attachment.

    • We want the wound to heal but in an open/elongated fashion (as opposed to “sewing” back together (re-attaching)). This is accomplished by doing woundcare exercises (often called stretches). This article describes very well how the wound is supposed to heal. And, the section below lists many videos and resources for doing post-frenotomy stretches/care.

    • It is very helpful to visualize the stretches and even practice them a bit prior to have a tie evaluation/procedure - so that you are ready to do them!

    2nd job - keeping the released areas healthy, stretchy and pliable

  • After a tie- release, and during the normal process of healing a new frenulum will grow - this starts to occur around 2-3 weeks post-procedure.

  • For this reason, we want the areas in and around the frenotomy sites to be flexible so that the new frenulum will grow in long and stretchy. This Instagram post does a great job of showing how that occurs.

  • This means that your second job - is to continue bodywork so that areas around the mouth (and in particular near the areas that were released) as well as the face, neck and body to be looser. This not only includes the ideas you worked on prior to release, but will also to incorporate more and more facial and intra-oral massage.

  • Work with your release provider, IBCLC, bodyworker, SLP, etc to determine the correct exercises and bodywork for your situation.

Resources for post-frenotomy care

Again - it is very important to study this topic and even practice it ahead of time. If you are short on time - the first few are excellent, and the rest offer extra ideas/help

  • Post-frenotomy woundcare/stretches:

    • Bobby Ghaheri video - note that many providers are no longer recommending sweeps of the wound every time, but only if you see attachment.

    • Mikel Newman video - this one shows very well what re-attachment might look like. Again, note that many providers are no longer recommending sweeps of the wound every time, but only if you see attachment.

    • The Sleeping Tongue Posture Hold by Michelle Emanuel. Excellent for promoting tongue lift/strength, closed mouth breathing, tongue/palate contact and palate widening, and a wonderful technique for getting a stretch while a baby is sleeping (make sure that the diamond is fully opened though - check other videos)

    • National Tongue Tie Centre video - this one is very interesting to watch - the baby is asleep the entire time (!) so the stretches are being done VERY slowly and steadily. If you try this at home, you may not achieve this, but it’s worth a watch because it shows a very good closeup of the diamond and how it opens.

    • A few videos with post-frenotomy care that include some playful ideas:

    • And, more videos by Amy Schecter; Lisa Lahey; Richard Baxter - similar to the above ones but it’s sometimes helpful to see/hear the information in different ways.

    • And, a more thorough overview of the whole process of getting ready for and doing the frenotomy process by Jessica Altemara - this excellent and thorough video goes over prepping (she calls it “pre-habbing”) for release, as well as various ideas for doing post-frenotomy stretches. She also links to ideas for practicing prior to release, homeopathy remedies and more (through the North Carolina Tongue Tie Center)

    • The baby needs time to heal and to re-learn how to use their newly free oral muscles. Here is an excellent handout sheet - the 5 “T’s of Tongue Tie and Lip Tie Post Revision Support” - (the 5 T’s are Time, Technique, Training, TummyTime, Therapy) - by Lisa Lahey, RN, IBCLC

    Soreness relief ideas

Take a moment to think about how you will help your baby with any soreness they may feel. Typically it is mostly the first night and the day after. Most babies do better than you imagine they will - but still it’s good to be ready.

<—- Tongue Ties, Part I ———-— Plugged Ducts and Mastitis ——>