How to cut a tongue-tie

How is a baby’s tongue-tie clipped?

Tongue-ties are most commonly cut with scissors (clipping) and this remains the gold standard. Recently, laser surgery has become popular. The latter is more expensive and may take longer to heal than clipping. Clipping a tongue-tie in a baby is usually done using a special tool to lift the tongue and stretch the frenulum, making it easier to cut. Most babies tolerate the procedure well, with little crying and bleeding. Tongue-ties can also be cut using a laser to burn away the frenulum. It seems relatively safe, but there is little information on the long-term risks and benefits. Babies can be given a small amount of a sugar solution right before the procedure to decrease the pain. Babies who breastfeed can be breastfed right afterward. Tongue-tie surgery can be done on healthy babies soon after birth, but sick babies should not have it until they are growing and healthy. 

A) When to cut a tongue-tie

Clipping a tongue-tie. A special tool (grooved director) lifts the tongue and scissors cut the frenulum.

Healthy babies may have a tongue-tie cut soon after birth. Toddlers and older children generally need sedation for the procedure, creating more risks for the child. For this reason, parents often decide to have the tongue-tie cut when their baby is young instead of taking a wait-and-see approach.

Cutting should be delayed until the baby is growing and healthy if the baby:

  • Is sick and unstable.
  • Has other abnormalities of the mouth.
  • Has muscle weakness.
  • Has a bleeding disorder.
  • Has not received vitamin K.
  • Has not been not been growing well.

B) How to cut a tongue-tie

A special tool (grooved director) to lift the tongue and stretch the frenulum.

A tongue-tie can be cut by:

  • Using:
    • Scissors (clipping)
    • A scalpel
  • By burning with:
    • A laser
    • Electricity (electrocautery)

Adults having tongue-tie surgery are often given local freezing before the procedure to control the pain, but babies are generally not as it does not appear to offer benefits and can pose risks (ABM 2004; Bhattad 2013; Messner 2020; Mettias 2013). Babies can be given a small amount of a sugar solution right before the cutting to decrease the pain and those who breastfeed can be put to the breast right afterward (Stevens 2016).

1) Cutting with scissors

Cutting the baby's tongue-tie with scissors (clipping) is often done using a special tool to lift the tongue and stretch the frenulum. The frenulum is then cut with scissors. This is the most common method for cutting a tongue-tie.  

Babies who have their tongue-ties clipped with scissors usually tolerate the procedure well, with little crying and bleeding afterwards (Griffiths 2004).

2) Laser surgery

Another kind of surgery uses electricity or a laser to burn the frenulum. This kind of surgery seals blood vessels, so there is generally no further action needed to stop bleeding. However, life-threatening bleeding can still happen (Kim 2020).

Laser surgery seems relatively safe, but there is a marked lack of information on the short- and long-term risks and benefits. Studies on the issue are poor (CADT 2016).

3) More aggressive surgery

In one study of the anatomy of the frenulum, there was no evidence that the deeper tissues of the frenulum, including the tongue muscle (genioglossus), prevented normal movement of the tongue (Mills 2019). They argue that there is no need for cuts to be made into the tongue muscle and that this only increases the risk of pain and scarring. As such, very deep cuts should be avoided.

Deep cuts may be necessary in rare circumstances and are performed by specialized surgeons. These require general anesthesia and the risk of complications is higher (Bahadure 2016; Khan 2017).

4) Choosing a method

To date, there are no published studies comparing the safety or effectiveness of these different methods (Hill 2020; Khan 2020; LeFort 2021; Messner 2020). Tongue-ties have been cut using scissors for a long time and this remains the gold standard (LeFort 2021). Animal studies show faster healing when scissors are used compared to laser surgery; this may also apply to babies. The delay in healing may be caused by heat injury to the frenulum and areas around it (LeFort 2021).

Individual prices vary but laser surgery is significantly more expensive than clipping.

C) Aftercare

It is important that babies are followed by their health-care providers after surgery to identify complications and ensure continued good growth.

Tongue-ties sometimes reattach themselves. The estimated rate of reattachment ranges from 0.003% to 13% (Brookes 2014). One study found that posterior tongue-ties were more likely to reattach (21%) than anterior ones (3.7%) (Hong 2010) . 

Reattachment can be seen as soon as one week after cutting with scissors and it is possible that further surgery can be prevented by tearing the new growth manually at that time (Nelson 2021).

Some health-care providers tell parents to stretch the baby’s wound after laser surgery so it does not scar and re-tighten. These stretching exercises are generally done several times daily for two to six weeks. Many mothers have told us the exercises are very painful and upset their babies and caused occasional bleeding of the wound. Experts have stated that there is no evidence to support massage or stretching after surgery (LeFort 2021; Messner 2020).

D) Complications

Minor bleeding is more likely with clipping then with laser surgery. It can be stopped with:

  • Pressure on the bleeding area.
  • Silver nitrate, which chemically seals the blood vessels.
  • A stitch.

Major and minor complications of tongue-tie cutting include (Solis-Pazmino 2020; Varadan 2019):

  • Infection
  • Bleeding (Tracy 2017;Walsh 2017)
  • Life-threatening bleeding (shock)
  • Infection (Isaiah 2013)
  • Life-threatening infection of the base of the mouth (Ludwig’s angina)
  • Cutting or injury of:
    • The salivary duct
    • The nerves of the tongue causing decreased feeling or movement
  • Cyst growth
  • Regrowth, reattachment, and scarring
  • New or worse feeding problems (Hale 2019)
  • New or worsening of existing speech problems
  • Airway blockage (Genther 2015; Hale 2019)
  • Refusal to take in milk by mouth (oral aversion)

References

Academy of Breastfeeding Medicine (ABM) [Internet]. New Rochelle: Academy of Breastfeeding Medicine; [date unknown]. Protocol # 11: Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. 2004 Aug 3 [cited 2018 Jun 10]
 
Bahadure RN, Jain E, Singh P, et al. Labial ankyloglossia: A rare case report. Contemporary Clinical Dentistry. 2016;7(4):555-557
 
Bhattad MS, Baliga MS, Kriplani R. Clinical guidelines and management of ankyloglossia with 1-year followup: report of 3 cases. Case Reports in Dentistry. 2013;2013:185803
 
Brookes A, Bowley DM. Tongue tie: the evidence for frenotomy. Early Hum Dev. 2014 Nov;90(11):765-8
 
Canadian Agency for Drugs and Technologies in Health (CADT). Frenectomy for the Correction of Ankyloglossia: A Review of Clinical Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2016 Jun 15
 
Genther DJ, Skinner ML, Bailey PJ, et al. Airway obstruction after lingual frenulectomy in two infants with Pierre-Robin Sequence. Int Pediatr Otorhinolaryngol. 2015 Sep;79(9):1592-4
 
Griffiths DM. Do tongue ties affect breastfeeding? J Hum Lact. 2004 Nov;20(4):409-14
 
Hale M, Mills N, Edmonds L, et al. Complications following frenotomy for ankyloglossia: A 24-month prospective New Zealand Paediatric Surveillance Unit study. J Paediatr Child Health. 2019;10.1111/jpc.14682

Hill RR, Pados BF. Symptoms of problematic feeding in infants under 1 year of age undergoing frenotomy: A review article. Acta Paediatr. 2020 Jul 12 
 
Hong P, Lago D, Seargeant J, et al. Defining ankyloglossia: a case series of anterior and posterior tongue ties. Int J Pediatr Otorhinolaryngol. 2010 Sep;74(9):1003-6
 
Isaiah A, Pereira KD. Infected sublingual hematoma: a rare complication of frenulectomy. Ear Nose Throat J. 2013 Jul;92(7):296-7

Kim DH, Dickie A, Shih ACH, et al. Delayed Hemorrhage Following Laser Frenotomy Leading to Hypovolemic Shock. Breastfeed Med. 2020 Dec 28

Khan U, MacPherson J, Bezuhly M, et al. Comparison of Frenotomy Techniques for the Treatment of Ankyloglossia in Children: A Systematic Review [published online ahead of print, 2020 Jun 2]. Otolaryngol Head Neck Surg. 2020;194599820917619 

Khan S, Sharma S, Sharma VK. Ankyloglossia: Surgical management and functional rehabilitation of tongue. Indian J Dent Res. 2017 Sep-Oct;28(5):585-587

LeFort Y, Evans A, Livingstone V, et al. Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads. Breastfeed Med. 2021 Apr;16(4):278-281

Messner AH, Walsh J, Rosenfeld RM, et al. Clinical Consensus Statement: Ankyloglossia in Children. Otolaryngol Head Neck Surg. 2020 Apr 14:194599820915457 

Mettias B, O'Brien R, Abo Khatwa MM, et al. Division of tongue tie as an outpatient procedure. Technique, efficacy and safety. Int J Pediatr Otorhinolaryngol. 2013 Apr;77(4):550-2
 
Mills N, Pransky SM, Geddes DT, et al. What is a tongue tie? Defining the anatomy of the in-situ lingual frenulum. Clin Anat. 2019 Jan 30

Nelson L, Prasad N, Lally MM, et al. Frenotomy Revision Rate in Breastfeeding Infants: The Impact of Early Versus Late Follow-Up. Breastfeed Med. 2021 Mar 30

Solis-Pazmino P, Kim GS, Lincango-Naranjo E, et al. Major complications after tongue-tie release: A case report and systematic review. Int J Pediatr Otorhinolaryngol. 2020 Sep 1;138:110356 

Stevens B, Yamada J, Ohlsson A, et al. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2016 Jul 16;7:CD001069
 
Tracy LF, Gomez G, Overton LJ, et al. Hypovolemic shock after labial and lingual frenulectomy: A report of two cases. Int J Pediatr Otorhinolaryngol. 2017 Sep;100:223-224
 
Varadan M, Chopra A, Sanghavi AD, et al. Etiology and clinical recommendations to manage the complications following lingual frenectomy: A critical review. J Stomatol Oral Maxillofac Surg. 2019 Jun 27. pii: S2468-7855(19)30159-4
 
Walsh J, Tunkel D. Diagnosis and Treatment of Ankyloglossia in Newborns and Infants: A Review. JAMA Otolaryngol Head Neck Surg. 2017 Jul 13