The goal of stretches/aftercare post-frenotomy (also know as frenectomy) is to help shape the scar tissue into a vertically oriented wound (not prevent it). The body will make a new neo-frenulum as it heals, this is normal. The exercises are not meant to be held for long, nor do they require much force.
After a release, as Osteopaths and IBCLCs we are less concerned with how the “ties look” and more interested in the functional improvements that have been obtained as a result of the procedure. Improvements are rarely instant, but occur gradually over a period of weeks and into months. Yet, the most common fear expressed by our parents is that of reattachment. In our experience reattachment is rare when:
1. The original procedure has been performed by a skilled provider
2. A “complete release” was performed, and not just the anterior fibres of the tethered lingual frenulum
3. The appropriate aftercare and treatment have been followed
Factors that may affect reattachment include:
- An improper release (Eg. only the anterior fibers have been released and tension remains in the more posterior/submucosal fibers.
- Incorrect finger positioning during stretches
- Not enough pressure or incorrect technique whilst lifting the wound
- Stretches performed too vigorously
- Muscle tension around the wound
- A baby who clamps/bites down and prohibits parents from completing stretches effectively
Strategies to help manage pain / discomfort post-frenectomy:
- Plenty of skin-to-skin
- Bath or shower
- Offer frequent breastfeeds
- If you are having difficulty latching try feeding whilst in the bath, walking around the house, or whilst babywearing
- Tummy time
- Gently massage coconut oil in the wounds
- Make a breastmilk slushy: blend up some frozen breastmilk and syringe it under their tongue
- Homeopathic pain remedy: speak with your provider first
Aftercare Stretches and Protocol: Dr. Bobby Ghaheri, ENT
- Wash your hands (gloves are optional)
- You can use coconut oil to assist with the stretches
- Swaddle your baby to keep their arms down – they get very good at getting their hands in the way of yours!
- Watch the below videos for a demonstration of how best to perform the aftercare exercises
- Start with the lip stretch first (if you have had a lip tie released)
- If you have had buccal ties released also, do as your provider has advised (but only do one stretch at a time, too much tension on the lip causes pain)
- You will find a more extensive explanation of wound aftercare, as well as answers to many commonly asked questions on tongue ties on Dr. Ghaheri’s website.
Most babies don’t like either of the stretches and may cry, so start with the lip as it will allow you to get under the tongue easier once the baby starts to cry. For the upper lip, simply place your finger under the lip and move it up as high as it will go (until it bumps into resistance). Then gently sweep from side to side. The main goal of this procedure is to insert your finger between the raw, opposing surfaces of the lip and the gum so they can’t stick together. No force is necessary.
- Hold 1-2 sec
- Stretch 6 x/day for 3 weeks (5 x in the day, 1 x overnight)
- Maximum of 6hrs between night-time stretches
Insert one index finger at a time, until you have both in the mouth. Then move your fingers under the tongue and lift it up towards the roof of baby’s mouth. The tongue needs three separate stretching motions:
- Once your fingers are under the tongue, try to pick the tongue up as high as it will go (towards the roof of the baby’s mouth). Hold it there for 1-2 seconds and then relax. The goal is to completely open up the diamond so that it’s almost flat (as the fold of the diamond across the middle is the first place it will reattach). The key to the success of this stretch is that your fingers are placed deep enough prior to lifting the tongue up. Picture how a forklift works. I recommend holding the chin down with your middle fingers whilst pushing your index fingers together to prevent them from separating, then lift the tongue up so that the middle of the tongue comes up with you. (Duration: 1-2 sec, Frequency: Week 1 = 1 x lift per session, Week 2 = 5x/session)
- With one finger propping up the tongue, place your other finger in the middle of the diamond and turn your finger sideways and use a lifting motion from low to high to try and keep the diamond as deep as possible. Use a lifting motion when you sweep through the diamond, trying to separate the horizontal fold across that diamond. Make sure your finger starts within the diamond when doing this stretch. This stretch should not be forceful or rough within the wound. (Duration: 5 seconds)
- Massage on either side of the diamond (outside the diamond) to loosen up the musculature of the remainder of the floor of mouth. You can use more pressure when doing these stretches because you aren’t in the wound at this point. (Duration: 5 seconds)
- One stretch on the first evening following frenectomy, next stretch on the morning after the procedure.
- 6 x times per day for 3 weeks. Do 5 stretches during the day around nappy changes, and one overnight. Do not go more than 6 hours between stretches.
- From the 4th week, drop one stretch per day before stopping completely by the end of week 4.
If there are signs of reattachment at the Week 3 post-frenectomy follow-up: You can prick a Vitamin E capsule (400IU) and squeeze the oil onto your index finger. Massage the oil up and down the band and roll the band (pseudofrenum) between your fingers for 5 sec (with pressure). Follow this with 5x tongue lifting exercises. Frequency: 3x/day for another 3 weeks, when baby is awake.
This may help reduce the chance of a reattachment requiring revision by 50-75% (anecdotally). Note: The impact of any reattachment is best determined between your IBCLC and the treating provider.
Protocol (Dr Ghaheri):
- Slowly rub the lower gumline from side to side and your baby’s tongue will follow your finger. This will help strengthen the lateral movements of the tongue.
- Let your child suck on your finger and do a tug-of-war, slowly trying to pull your finger out while they try to suck it back in. This strengthens the tongue itself. This can also be done with a pacifier.
- Let your child suck your finger and apply gentle pressure to the palate. Once the baby starts to suck on your finger, just press down with the back of your nail into the tongue. This usually interrupts the sucking motion while the baby pushes back against you. Listen for a seal break and then put your finger back up into the palate to re-stimulate sucking. Repeat as tolerated.
- With one index finger inside the baby’s cheek, use your thumb outside the cheek to massage the cheeks on either side to help lessen the tension.
- In the lead-up to the procedure: 4 times per day
- Post-procedure: begin on day 3 after the procedure, 30-45 sec on each stretch, prior to wound stretches.
- No night time exercises required
- Cease at end of week 4, after consultation with your Osteopath/Lactation Consultant (IBCLC).