Frenotomy: Procedure, Benefits, Risks, Recovery and Alternatives

Frenotomy—most often performed to treat tongue-tie (ankyloglossia)—is a simple surgical procedure that has seen a dramatic rise in recent years, especially for newborns with breastfeeding difficulties. But what actually happens during the procedure? What are the real benefits and potential risks, and how does recovery unfold? Importantly, what alternatives are available? This article explores these questions, offering evidence-based insights to empower families and clinicians in making informed decisions.

Frenotomy: The Procedure

Frenotomy is a minor surgical intervention that involves cutting the lingual frenulum—the small band of tissue connecting the underside of the tongue to the floor of the mouth. This procedure is primarily performed in infants and young children whose tongue-tie restricts tongue movement, leading to challenges with breastfeeding, speech, or oral hygiene.

Purpose	Techniques	Anesthesia	Safety/Outcomes (Source)
Relieve tongue restriction	Scissors, scalpel, laser, or electrosurgery	None, local, or general	Generally safe; minor complications most common 1 2 3 4 15

Table 1: Key Aspects of the Frenotomy Procedure

Indications for Frenotomy

Frenotomy is most frequently carried out in infants experiencing breastfeeding problems such as poor latch, ineffective milk transfer, or maternal nipple pain. In older children, speech and articulation difficulties, as well as restricted tongue movement, may prompt consideration of the procedure 1 2 3 7.

How the Procedure is Performed

• Setting: Typically performed in a clinic or outpatient setting for infants, sometimes in an operating room for older children or complex cases.
• Technique:
  • A healthcare provider uses sterile scissors, a scalpel, or sometimes a laser or electrosurgical device to snip the tight frenulum.
  • For infants, the procedure is quick—often completed in seconds—and may require no anesthesia or just a topical anesthetic. For older children or complex cases, local or general anesthesia may be used 1 3 15.
• Aftercare: Babies are often breastfed immediately after the procedure, which can help soothe them and confirm improvement in tongue movement 3.

Who Performs Frenotomy?

Frenotomy may be performed by pediatricians, otolaryngologists (ENTs), dentists, midwives, or lactation consultants, depending on local regulations and practitioner experience 4 5.

Safety and Immediate Outcomes

The procedure is generally safe, with minor complications such as brief bleeding or mild discomfort being most common. Major complications are rare but have been reported, particularly with laser techniques or if performed by less experienced practitioners 3 4 11 12.

Benefits and Effectiveness of Frenotomy

The decision to proceed with frenotomy is often driven by the desire to improve feeding and reduce associated maternal pain. But what does the evidence say about its true benefits?

Indication	Reported Benefit	Evidence Strength	Source
Breastfeeding	Improved latch, less pain	Moderate	2 3 6 7 8 9 10 15
Speech	Possible articulation benefit	Weak/limited	1 2 15
Recurrence	Rare need for repeat procedure	Variable	1 2 11

Table 2: Reported Benefits of Frenotomy

Breastfeeding Outcomes

• Numerous studies and randomized controlled trials report that frenotomy leads to immediate and significant improvement in breastfeeding effectiveness, particularly in latch and maternal nipple pain 2 3 6 7 8 9 10 15.
• Mothers consistently report less nipple pain and greater confidence (self-efficacy) after frenotomy 6 7 8 10.
• Objective improvements in feeding are more pronounced in infants with more severe tongue-tie, though evidence for long-term breastfeeding success is less robust 8 9 10.

Speech and Oral Function

• Frenotomy may be considered for speech or articulation issues in older children, but high-quality evidence supporting improvements in speech is limited and inconsistent 1 2 15.
• Some studies suggest better tongue mobility and possible speech benefits, but routine prophylactic frenotomy for future speech issues is not recommended due to insufficient evidence 2 15.

Rates of Success and Need for Repeat Procedures

• Most infants and children see improvement after a single frenotomy, with repeat procedures required in a minority—particularly when initial cuts are incomplete or in cases of posterior tongue-tie 1 2 11.
• Success rates (defined as improved feeding or reduced pain) are very high, often exceeding 80–90% in studies focusing on breastfeeding outcomes 3 5.

Risks and Side Effects of Frenotomy

While frenotomy is generally safe, it is not entirely free of risks. Understanding the full spectrum of possible complications—both minor and major—is vital for informed consent.

Risk	Frequency	Severity	Source
Minor bleeding	Common	Mild	2 3 4 12 15
Pain	Occasional	Mild to moderate	3 7 11
Oral aversion	Uncommon	Moderate	11
Major complications	Rare	Severe	4 12

Table 3: Risks and Side Effects of Frenotomy

Common and Minor Complications

• Bleeding: Brief bleeding lasting 1–2 minutes is the most frequently observed complication, usually resolving without intervention 2 3 12.
• Pain: Some infants may experience mild discomfort or require a mild analgesic, though pain is typically short-lived 3 7.
• Repeat Procedures: About one-third of children treated under local or no anesthesia may require a repeat procedure, often due to incomplete division 1 11.

Less Common and Major Complications

• Oral Aversion: Some infants develop temporary aversion to feeding or oral stimulation, especially after laser procedures 11.
• Infection or Ulceration: Rare, but possible, particularly if post-procedure care is inadequate 4 12.
• Serious Events: Rare cases of severe bleeding, hypovolemic shock, and airway obstruction have been reported, especially following laser frenotomy in neonates 4 12.

Risk Factors

• Technique: Bleeding is more common with scissors/scalpel, while oral aversion is more likely with laser or electrosurgical devices 11.
• Experience: Complications are more common when the procedure is performed by less experienced practitioners or without proper assessment of indications 4 11.

Misdiagnosis and Unnecessary Procedures

• Up to 27% of referred cases may be due to inadequate breastfeeding support rather than true tongue-tie, highlighting the importance of comprehensive assessment 11.

Recovery and Aftercare of Frenotomy

After the procedure, most infants and children recover quickly, but optimal outcomes depend on proper aftercare and support.

Recovery Speed	Typical Aftercare	Complications	Source
Rapid (minutes–days)	Immediate feeding, possible exercises	Rare	3 13 14 15

Table 4: Recovery and Aftercare Highlights

Immediate Recovery

• Most infants can breastfeed or feed by bottle within minutes after the procedure, which helps soothe and assess improvement 3.
• Mild discomfort or fussiness may be present for a short time.

Wound Healing

• Healing is typically rapid, with most wounds closing within a few days to a week.
• Studies comparing surgical and laser techniques for related procedures suggest that laser may offer slightly better healing outcomes, though both are effective 13 15.

Aftercare Recommendations

• Tongue Exercises: Some providers recommend post-operative tongue exercises to prevent reattachment and encourage full range of motion, but protocols are highly variable 14.
• Pain Management: Mild analgesics may be used, but most infants do not require medication 3.
• Monitoring: Parents are advised to watch for signs of bleeding, infection, or feeding difficulties. Immediate medical attention may be needed if persistent bleeding or respiratory distress occurs 4 12.

Variability in Aftercare

• There is no universally accepted post-operative care regimen. Practices vary widely regarding exercises, follow-up, and feeding recommendations 14.

Alternatives of Frenotomy

Not all infants and children with tongue-tie require surgical intervention. Exploring alternatives—and ensuring a proper diagnosis—is crucial.

Alternative	Indication	Effectiveness	Source
Lactation support	Mild-moderate feeding issues	Often effective	5 9 10 11
Observation	Mild or asymptomatic cases	Appropriate	9 10 15
Frenuloplasty	Complex or recurrent cases	Effective	1 15

Table 5: Alternatives to Frenotomy

Comprehensive Lactation Support

• Many feeding issues can be resolved through skilled lactation consultation, addressing latch technique, positioning, and other non-surgical factors 5 9 10 11.
• In some studies, improved breastfeeding support reduced the need for surgical intervention 10 11.

Watchful Waiting

• Not all tongue-ties cause functional limitations. In cases where feeding or speech is not impaired, observation is reasonable 9 10 15.
• Reassessment over time can help determine if intervention becomes necessary as the child grows.

Frenuloplasty and Other Surgical Alternatives

• For cases where frenotomy is insufficient—such as thick or posterior tongue-ties or recurrences—a more extensive procedure like frenuloplasty may be considered. This involves more complex surgical repair, often under general anesthesia 1 15.
• Studies suggest both frenulotomy and frenuloplasty are safe and effective, with technique chosen based on individual anatomy and needs 1 15.

Importance of Accurate Diagnosis

• Before considering any procedure, thorough assessment is essential to distinguish true ankyloglossia from other causes of feeding or speech problems—and to avoid unnecessary surgery 11.

Conclusion

Frenotomy is a widely performed, generally safe, and often effective procedure for infants and children with symptomatic tongue-tie. However, like any intervention, it carries risks and should be considered within the context of a thorough assessment and after exploring non-surgical options.

Key Takeaways:

• Procedure: Frenotomy is a quick, minor surgical release of the tongue's frenulum, most often performed for breastfeeding or speech issues 1 2 3 15.
• Benefits: Strong evidence supports short-term improvements in breastfeeding effectiveness and maternal pain relief. Speech benefit evidence is weaker 2 3 6 7 8 9 10 15.
• Risks: Most complications are minor (brief bleeding, mild pain), but rare severe events have been documented, especially with lasers or in complex cases 2 3 4 11 12 15.
• Recovery: Healing is rapid, and most infants feed immediately after. Aftercare varies and may include exercises or pain management 3 13 14 15.
• Alternatives: Many cases improve with lactation support or observation. Frenuloplasty is reserved for select situations 5 9 10 11 15.
• Assessment: Accurate diagnosis and involvement of lactation professionals are critical to avoid unnecessary procedures and optimize outcomes 10 11.

Families and clinicians should work together to ensure that frenotomy is only performed when truly indicated, with a clear understanding of its potential benefits, risks, and recovery process.