Upper Lip Tie and Its Treatment
by Dr. Christopher Chang, last modified on
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Related to tongue tie (and its posterior hidden variant) which may cause problems with breast-feeding, upper lip tie is when the upper lip is tethered to the upper gum. Though most infants have some degree of upper lip tie, when it becomes large and tight enough, it may prevent the upper lip from flaring out or curling up which is essential for breast-feeding in order to create an adequate seal with the breast. Also, some infants with upper lip tie will exhibit an upper lip crease with the skin turning pale in an attempt to flare up during breast-feeding.
If the upper lip tie is tight enough, an infant may have trouble feeding even from a bottle.
- Prolonged breast-feedings
- Difficulty with latching
- Painful nipples (secondary to infant's struggling to achieve an adequate seal against the breast)
- Infant is excessively gassy
A good seal helps the baby draw the nipple deeply into the mouth and assists in the suck in order to swallow the milk produced by the breast. When a good seal is absent, excessive amount of air is introduced into the infant's mouth which is also swallowed along with the milk causing a too-gassy infant. Furthermore, lack of a good seal makes it more difficult for the infant to maintain the nipple's position in the mouth making for a prolonged and uncomfortable feeding.
To understand better, let's use an analogy of a suction cup against a window. In order for a suction cup to have a nice tight vacuum seal against the window, the "lips" of the suction cup should be flared out. If the lips of the suction cup are curled in, a good tight seal is absent as air will leak in resulting in the suction cup "losing" its latch against the window.
Watch video to see how the upper lip affects breastfeeding.
Treatment is recommended ONLY if the upper lip tie is causing a problem. If no symptoms are exhibited, one does not need to pursue any treatment unless there is a concern for future inadequate milk supply. Regarding upper lip ties and controversial influence on upper front teeth gaps, click here.
Other physical signs that upper lip tie may be contributing to breastfeeding problems include:
- Upper lip skin creasing when attempting to flip the upper lip up
- Skin of the upper lip turns pale when attempting to flip the upper lip up (due to cutting off the blood circulation)
Upper lip tie release treatment itself is fairly straightforward. If the child is less than 6 months of age, it may be possible to perform in the clinic under topical anesthesia only. If older than 6 months, sedation in the operating room may be required as the child is usually too uncooperative.
In our office, upper lip tie releases are most commonly performed using a
Steps to Procedure:
The upper lip tie is visualized and topical lidocaine is applied using a Q-tip. Injection of lidocaine may also be performed depending on the age of the patient and how thick the frenulum is.
The upper lip tie is clamped across with an instrument for about 10 seconds. This maneuver crushes the blood vessels closed so when the cut is performed, minimal bleeding occurs. Alternatively, a
LASERcan be used to make the cut without any mucosal clamping. Although there are pros and cons to each technique, regardless of the method used, outcomes and healing are excellent. Read more about LASER vs scissor technique. Here is a video showing a LASER upper lip tie release being performed.
The clamp is released and scissors (or
LASER) are used to cut right along the upper lip tie where the clamp was placed. No sutures are required.
That's it! This whole procedure usually takes no more than a few minutes.
Other Related Topics
Click here to see some pictures of what the wound looks like after the procedure.
The Upper Lip Still Does Not Flange Up After Release!
Keep in mind that even after the upper lip tie has been released, the upper lip may still not flange up properly with latch. That's because most human beings lack the lip muscle to flange the upper lip. This situation is analogous in the same way that most human beings lack the ability to wiggle the ears.
As such with attempted latch, the upper lip needs to be manually flanged either by grabbing the upper lip and flanging it up, or by flicking the upper lip up with a pinky from the corner of the mouth.
After the procedure, tylenol or motrin alone (if even that) is enough for pain control if > 6 months. Infants < 6 months do not typically require anything, but coconut oil, or Orajel Naturals (not regular Orajel) may be applied for pain control. Rarely, if tylenol or motrin needed, dosing chart below.
No antibiotics are needed. Frank bleeding (if occurs) will typically stop within 15 minutes. There may be a drop or 2 of blood that appears in the area for a few hours. The patient may immediately resume a diet without restrictions.
It is not unusual for a white eschar to appear along the cut edge. Do not worry if this happens. It is just a scab that is wet (recall what a scab looks like on your hand if you get it wet... it turns white). It will disappear in about 1 week.
An upper lip tie after being released has a high tendency to scar back together over a few weeks (~80% risk) causing a recurrence of the upper lip tie. This is because the upper lip rests right on top of the gum all the time except during feeding thereby allowing the cut edges to be laid on top of each other more often than not. In order to minimize this recurrence risk, the mother can firmly press a finger right on top of the wound into the groove between the gum and upper lip and exert pressure up towards the nose 5 times a day for 2 weeks to prevent any adhesions that may form. The pressure should be exerted for about 2 slow seconds each time.
I also encourage all parents to follow-up with a lactation consultant within a week after the procedure. Good lactation consultant practices local to our office include:
• Premier Lactation Services (provides private home visits, weekend visits, and free phone consultations)
• Angela Love-Zaranka, IBCLC, RLC
• INOVA Loudoun Lactation Center
• Fauquier Health Lactation Consultants (540-316-4011)
Post-procedure instructions can be downloaded here.
Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope. 9/19/16. DOI: 10.1002/lary.26306
Management of posterior ankyloglossia and upper lip ties in a tertiary otolaryngology outpatient clinic. Int J Pediatr Otorhinolaryngol. 2016 Sep;88:13-6. doi: 10.1016/j.ijporl.2016.06.037. Epub 2016 Jun 18.
Breastfeeding difficulties and oral cavity anomalies: The influence of posterior ankyloglossia and upper-lip ties. Int J Pediatr Otorhinolaryngol. 2015 Jul 31. pii: S0165-5876(15)00368-7. doi: 10.1016/j.ijporl.2015.07.033.
The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. Int J Pediatr Otorhinolaryngol. 2013 May;77(5):827-32. doi: 10.1016/j.ijporl.2013.02.022. Epub 2013 Mar 22.
Evidence of improved milk intake after frenotomy: a case report. Pediatrics. 2013 Nov;132(5):e1413-7. doi: 10.1542/peds.2012-2651. Epub 2013 Oct 7.
Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008 Jul;122(1):e188-94. doi: 10.1542/peds.2007-2553. Epub 2008 Jun 23.
Tongue movement and intra-oral vacuum in breastfeeding infants. Early Hum Dev. 2008 Jul;84(7):471-7. doi: 10.1016/j.earlhumdev.2007.12.008. Epub 2008 Feb 11.
Ankyloglossia (tongue-tie): a diagnostic and treatment quandary. Quintessence Int. 1999 Apr;30(4):259-62.
Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. J Hum Lact. 2013 Nov;29(4):458-64. doi: 10.1177/0890334413491325. Epub 2013 Jul 2.
Tylenol and Motrin Infant Dosing Chart
For Tylenol (may give every 4 hours, but no more than 5 doses in 24 hours): Infant and Children's liquid tylenol are identical in concentration. Suppositories also available by prescription.
6-11 Pounds --> 40 mg which is 1.25 ml (1/4 teaspoon of infant liquid Tylenol)
12-17 Pounds --> 80 mg which is 2.5 ml (1/2 teaspoon of infant liquid Tylenol)
18-23 Pounds --> 120 mg which is 3.75 ml (3/4 teaspoon of infant liquid Tylenol)
For Motrin (ibuprofen) (may give every 6 hours, but no more than 4 doses in 24 hours): Please note that infant drops are NOT the same concentration as Children's liquid which is more concentrated.
12-17 Pounds --> 50 mg which is 1.25 ml (1/4 teaspoon of infant drops)
18-23 Pounds --> 75mg which is 1.875ml (1 syringe of infant drops)
24-35 Pounds --> 100mg which is 2.5ml (1/4 teaspoon of infant drops)
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- Buccal Ties and Breastfeeding
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- Laser vs Scissor Technique for Tongue/Lip Tie Release
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