398 Section IX ■ Miscellaneous Procedures

Refer to appropriate surgeon for consideration for

frenuloplasty.

2. Known bleeding disorder (e.g., hemophilia)

Refer to otolaryngologist for repair in the operating

room.

F. Limitations

1. If the difficulty with breast-feeding was not caused by

the tongue tie, release of the tongue tie will not result

in improvement.

2. Even when tongue tie is the cause, to ensure the best

outcome attention must be paid to latch and suckling

after release.

Postfrenotomy, it is not unusual for a period of suck

training, by an appropriately trained lactation specialist, to be required to correct abnormal tongue movements. Follow-up with a trained lactation specialist is

extremely important for breast-feeding success.

G. Equipment

Sterile

1. Iris scissors

2. Grooved retractor (optional—see below) (Fig. 57.3)

3. Gloves

4. Gauze pads

5. Topical anesthetic gel for oral use (optional—see

below)

6. Cotton swab

7. Topical Neo-Synephrine, Gelfoam, or silver nitrate

sticks (optional—see H, below)

Nonsterile

1. Blanket or towel for swaddling

H. Precautions (Fig. 57.3)

1. Ensure, by careful examination of the frenulum, that

there is no vascular or muscular tissue in the field of

incision. Transillumination may be used to enhance

visualization.

2. Avoid submandibular duct orifices lateral to the frenulum.

3. Avoid the thicker, most posterior, part of the frenulum,

which carries the blood supply.

I. Technique (2,3,9,18,21,26,27)

(Figs. 57.2 and 57.3)

1. Place the infant on a firm surface, or in caregiver’s lap

with head against caregiver’s lower abdomen.

2. Firmly swaddle the infant in a blanket or towel (see

Chapter 4).

3. Have an assistant standing at the head of the infant to

stabilize the shoulders with their fingers while steadying the head with their palms, or have a caregiver do

the same with the infant in their lap.

4. Stand on right side of infant if right-handed.

5. Visualize the frenulum by positioning light source to

the left of the infant, allowing essentially transillumination of the frenulum.

6. Place two gloved fingers of the left hand below the

tongue, on either side of the midline, or one gloved finger below the tongue to one side of midline, or position

a grooved retractor (whichever you find most comfortable), to push the tongue up toward the roof of the

mouth, exposing the frenulum (Fig. 57.3.). Inspect the

frenulum for any vascular or muscular structures.

7. Frenotomy should be performed only if the frenulum is

thin, transparent, and free of other structures.

8. Utilization of local anesthesia (optional)

a. With no anesthesia, there is minimal, brief discomfort (8,13,18,21,26,30) because the frenulum is

poorly innervated.

 Infants frequently squirm with positioning, but

usually do not cry during procedure.

b. Topical anesthetic gel can be applied to the frenulum with a cotton swab.

9. Divide the membranous frenulum with iris scissors

(Fig. 57.4).