Frenotomy Tools: Scissor vs. Laser

Tongue and lip ties can significantly impact an infant's ability to breastfeed effectively, which can lead to a host of challenges for both the baby and the parents. Fortunately, tongue and lip tie releases, also known as frenotomies or frenectomies, are procedures that can address these issues. This blog will explore the tools used for these procedures, the medical providers who perform them, the associated risks, and the precautions to take.

Please note: This discussion bypasses important aspects of treatment of oral restrictions, including how to perform a functional assessment, when to suggest frenotomy, and other therapies that can be used to prepare for, and recover from, the procedure. There are other resources on these topics that can be found on this website or on episodes of the Tongue Tie Experts Podcast. This article is all about the actual procedure, and focusing on treatment of an infant in the breastfeeding stage.

The decision of which tool to use or recommend, ultimately lies with the professional performing the procedure. If you are a medical, birth or perinatal professional who is on the Tongue Tie Team, even if release is not in your scope of practice, it is often necessary to provide information to guide your patients and clients to an informed decision about frentomy procedures. I promise, you will be asked your opinion. It is my hope that the information in this discussion will guide you to support you as you educate your own patients.

What Are Tongue and Lip Ties?

Tongue tie (ankyloglossia) and lip tie occur when the frenulum aka frenum, the small band of tissue that connects the tongue to the floor of the mouth or the lip to the gum, is too tight, short or too restrictive. This can cause functional deficits related to the use of the tongue. If the tongue can not freely move it can lead to difficulty with breastfeeding, feeding and speech challenges, and airway dysfunction. Here we are concerned with infant breast or bottle feeding.

Tools Used for Tongue and Lip Tie Release:

The two types of tools we will review today are scissors and laser.

Scissor:

Scissor release is a traditional method using sterile surgical scissors to cut the frenum. It's a quick procedure often performed in a medical office. This may or may not be enough release to provide functional movement. It depends on the provider’s skill level and experience with functional assessment (see below).

While generally safe, there are several risks and potential complications associated with this method. Scissor procedures often result bleeding compared to laser techniques. Usually, skillfully applied pressure stops the bleeding quickly. For some families, even a small amount of blood in the mouth can be upsetting. In rare cases, there can be significant bleeding that requires additional measures to control, such as cauterization, or application of medication or stitches.

Wound infection is a possible complication of the use of scissors. The open wound created can be susceptible to bacterial infection. Proper aftercare and hygiene are essential to minimize this risk.

Pain and Discomfort can be experienced by infants during and after a scissor frenotomy due to the nature of the cut and the potential for tissue trauma. Analgesia should be considered, even for infants who can’t tell us when they are in pain.

An overzealous release or improper wound care can lead to scar tissue formation at the site of the incision. This scarring can sometimes affect tongue mobility and may require further intervention

The complication that I have seen most in my professional, clinical practice is incomplete release of the tongue. Scissor frenotomy often doesn’t fully release the tongue tie, especially if it’s a provider who hasn’t had enough training in the functionality of the tongue muscles. Many infants who have had scissor release go on to have laser revision to achieve full mobility of the tongue. Similarly, I have noted higher reattachment rates after scissor frenotomy, usually if the procedure was performed without recommending aftercare exercises or lactation support to facilitate at the breast feeding.

Laser:

The tool that I prefer to recommend, is the CO2 Laser. Full disclosure, I have had a financial relationship with the most popular laser company in the US, helping to train the dentists and doctors who are using their products. There is good reason that I decided to support this company - in my experience it is the best tool for the procedure, and I’ll explain why the CO2 laser is a popular choice among medical professionals due to its precision and numerous benefits.

The CO2 laser emits a concentrated beam of infrared light that vaporizes the water molecules within soft tissue. This process allows for precise cutting with minimal damage to surrounding tissues. Precision and Control are vital for this procedure. The laser provides excellent precision, allowing for controlled tissue removal and minimal collateral damage. This precision is particularly beneficial in delicate areas such as the mouth. Remember the complication mentioned above - risk of bleeding? The laser coagulates blood vessels as it cuts, significantly reducing bleeding during the procedure. This hemostatic effect minimizes the need for sutures due to control of bleeding. While there is a theoretical risk of bleeding in any surgical procedure, it is limited with laser use. Of course, bleeding disorders, and other health histories need to be considered, and skill of the provider who is using the laser can effect outcomes, but in general, the risk of bleeding is minimized compared to scissor release.

The other complication mentioned previously, wound infection, is almost completely eliminated with this type of laser release. The CO2 laser sterilizes the tissue surface as it cuts, reducing the risk of postoperative infections. In all of my years observing post op frenotomy wounds, I have never seen an infection at the site of frenotomy release.

There are reports that Pain is less postoperatively with laser frenotomy compared to traditional methods. The laser's ability to precisely target tissue reduces trauma, contributing to a more comfortable recovery. Although I’d still recommend discussing analgesia with a provider.

Types of Medical Providers to consider:

• Pediatricians: Often the first to diagnose tongue or lip ties, pediatricians can perform the release in their office, especially if the procedure is to correct an obvious, anterior tongue tie.
• ENT Specialists (Otolaryngologists) or Oral Surgeon: These doctors specialize in conditions of the ear, nose, and throat and can perform more complex releases. Be cautious regarding those who feel that an operating room and general anesthesia is necessary, as neither are typically needed in the newborn stage.
• Dentists and Pediatric Dentists: Dentists, particularly those specializing in pediatrics, frequently use lasers for frenectomies.
• Lactation Consultants: While not performing the surgery, lactation consultants play a crucial role in identifying tongue and lip ties, understanding other therapies, preparing the family and referring to the appropriate medical providers.

To ensure a smooth procedure and recovery, consider the following precautions:

• Choose an Experienced Provider: Ensure the medical provider is experienced in performing tongue and lip tie releases. Ask about their training and experience with both methods. Ask about results and aftercare, before the procedure. It is more important to have a provider who is experienced with a tool, then a particular tool. Chose someone based on their expertise with the scissor or laser, not based on the tool itself.
• Post-Procedure Care: Follow all post-procedure care instructions provided by your medical provider. This may include stretches or exercises to prevent reattachment, managing pain, and monitoring for signs of infection.
• Breastfeeding Support: Work with a lactation consultant before and after the procedure to address any breastfeeding challenges and to ensure proper latching and feeding techniques.
• Monitor Healing: Keep an eye on the healing process. If you notice any signs of infection, excessive bleeding, or if your baby's feeding difficulties persist, contact your healthcare provider immediately.

In Conclusion:

Tongue and lip tie releases can significantly improve breastfeeding outcomes and overall oral function for infants. Understanding the tools used, the types of providers who perform the procedure, the associated risks, and the necessary precautions can help professionals to guide parents to make informed decisions. Always consult with healthcare professionals to determine the best course of action for your child's needs. This article is not meant to be personal medical advice.

For further information download here: Preparing for Day of Frenotomy 

References:

Garrocho-Rangel A, Herrera-Badillo D, Pérez-Alfaro I, Fierro-Serna V, Pozos-Guillén A. Treatment of ankyloglossia with dental laser in paediatric patients: Scoping review and a case report. Eur J Paediatr Dent. 2019 Jun;20(2):155-163. doi: 10.23804/ejpd.2019.20.02.15. PMID: 31246095.

Mazzoni A, Navarro RS, Fernandes KPS, et alEvaluation of the effects of high-level laser and electrocautery in lingual frenectomy surgeries in infants: protocol for a blinded randomised controlled clinical trialBMJ Open 2021;11:e050733. doi: 10.1136/bmjopen-2021-050733