“That is great question, because training varies so much,” noted Dr. Truong. “I think it should be someone who knows the anatomy well and can take care of any complication, including major bleeding, infection, risk to the airway, and damage to local structures in the mouth.”
Explore This Issue
April 2023“We’re skilled at recognizing the pertinent structure underneath the tongue,” Dr. Messner added. “Also, most insurance plans will cover the procedure when it is performed by an otolaryngologist, which improves access to the procedure.”
Before the renewed interest in breastfeeding, if you were to cut a tongue tie, it was considered quackery. Now the pendulum has swung the other way: If you don’t cut a baby’s tongue tie, you are withholding a lifesaving procedure. —Mai Thy Truong, MD
Dr. Ghaheri also believes that otolaryngologists should be the ones performing these procedures. “It should absolutely be otolaryngologists, because we are the masters of the airway.” A pediatric dentist doesn’t have the level of training in airway management and may not know that the airway might be at risk, he added.
In addition, pediatrics experts agree that the procedure should be performed by someone who understands the basics of breastfeeding mechanics (Pediatrics. 2008;122[1]:e188–e194).
It’s All in the Technique
Perhaps the better question to ask is what technique should be used, noted Dr. Truong. “When I train residents on this procedure, the most important thing is to lift the tongue and expose the frenulum well. I snip the frenulum and then apply pressure and reevaluate to make sure that I’ve safely removed all of the frenulum. In the majority of cases, [a complete frenotomy] requires more than one cut,” she said. “It’s also important that residents understand the mechanics of breastfeeding, so we review ultrasounds of a breastfeeding infant and discuss maternal issues, such as varying nipple anatomy and issues of milk supply. I encourage working with a lactation consultant.”
Dr. Messner agreed. “I think that when a frenotomy is done properly on a type 1, type 2, or even a prominent type 3 tongue tie, the incision must lyse the entire frenulum but not go into the musculature of the tongue. It’s a matter of doing a complete frenotomy versus a non-complete procedure.”
“As residents, we’re taught to use a pair of hemostats to crush the frenulum and then cut it after we squeeze out the blood flow, which can actually cut muscle,” Dr. Ghaheri said. “With my technique, you go around the muscle, cutting the mucus membrane, not cutting into any muscles at all.”