Does your baby have an upper lip-tie or buccal ties?
Babies' oral frenula (or oral connective tissues) are highly variable
Once you understand how a baby sucks at the breast, you'll understand why there is never a reason to perform a labial frenotomy (that is, frenotomy on the frenulum under a baby's upper lip) or frenotomy of (what might be labelled as) a posterior tongue-tie. That is, there's never reason to perform frenotomy in the absence of a visible, very prominent membrane running a long way along the undersurface of baby's tongue, and tethering the tip of the tongue.
You can find out about classic tongue-tie here.
If you are being diagnosed with these problems, it is because the provider or health professional helping you is (with only the very best intentions to help you on their part) unwittingly affected by our health system's blind spot about fit and hold during breastfeeding.
What do you need to know about the diagnosis of upper lip-tie?
The shape of and insertions of the frenulum (that fleshy midline piece between the upper lip and gum) are highly variable.
If the upper lip frenulum inserts down close to or on or even under the upper gumline, many breastfeeding support professionals still claim that the labial (or upper lip) frenulum is tied. This belief comes from outdated biomechanical models, which believe that the lips have to grasp the breast or flange or turn out in a 'special K', in order for the baby to stay on the breast and effectively breastfeed. This is not true.
You can find out how babies actually suck during breastfeeding here. I first put this model together from clinical experience and ultrasound studies, calling it the gestalt model of infant suck during breastfeeding.
With the help of Professor Laurie Walsh, I'd gathered together a team of clinicians and researchers in 2018 who published the first article internationally stating that there was no place for labial frenotomy
Since then, in 2020, a pioneering MRI study by ENT surgeon Dr Nikki Mills confirmed in a live study of 11 successfully breastfeeding babies that baby's lips are usually neutral (not flanged) during successful breastfeeding. The lips were not flanged or 'everted' in eight of the 11 babies.
Labial (or upper-lip) frenotomy actually places babies at increased risk of a gap between their front teeth, due to scarring - not to mention unnecessary pain and risk of bleeding and infection.
The whole range of insertions of a labial frenulum is normal in infants, including very low insertions on the gumline and wide fleshly frenula. If you lift the upper lip up and stretch it towards the nose enough, you will most likely see some blanching at the insertion of the frenulum on the gum. This is normal, because you are putting the frenulum under pressure. The frenulum is doing its job, tethering the lip to the gum.
If you can see your baby's lips, she will not be drawing up large amounts of breast tissue into her mouth. For many, visible lips results in nipple pain and fussy baby behaviour at the breast. With a deep face-breast bury the lips are not visible, and I explain to women that it doesn't actually matter what the lips are doing - they are not relevant to the breastfeeding process, other than as part of the lower face's seal against the breast.
If your baby has one of those fleshy labial frenula that insert at the margin of the upper gum, this insertion will typically move upwards as your little one grows. Once the adult teeth come through, about age 7, there will be a very small proportion of children who might benefit at that time from a frenotomy of the labial frenulum. Once the adult teeth have erupted, a very low insertion of the labial frenulum may cause a gap between the front teether, or diastema. Even so, it may not be appropriate to perform a frenotomy on a seven-year-old. But labial frenotomy is definitely not appropriate on a baby!
We don't want to see baby's lips flanging during breastfeeding if we are to draw up as much breast tissue as possible and eliminate breast tissue drag
The baby's lips are another sensitive sensory organ. I will never forget the joy of my babies' kisses, those moist little mouths that loved to suck on my face or my arm or my neck or my breast! I loved to kiss my babies, and I still remember, sitting here quietly writing, how my babies loved to kiss me back (which was really them trying to suck on me!)
When the baby is coming to the breast and then suckling, it is best to ignore the lips. Don't wait for wide gapes, don't try to line up nipple to nose, and definitely don't pull the breast tissue back to see what the lips are doing, as this pulls breast tissue out of the baby's mouth. The orbicularis oris is the complex circular muscle around the mouth. You can see that massage exercises which aim to relax the orbicularis oris muscle arise out of a mistaken understanding of the role of the baby's lips.
It is normal for our baby's lips and chin and tongue to quiver at times, and this is not a sign of worrying fatigue, or any other problem.
What do you need to know about the diagnoses of bucccal ties?
Some babies also receive buccal frenotomies, a lasering of any tethering tissue up under the lips, at the upper margin of the gum and fleshy lips. Again, there is no rationale (once you know how babies suck at the breast) nor science to support this intervention. The cosmetic outcomes in later life are unknown.
Photo 1
Photo 2
Photo 3
The baby in the photo below had been given upper lip, buccal and lingual frenotomies. I was concerned by the unusual laxity of the upper lip post-frenotomies, and what the cosmetic implications might be in later life. You'll can see that when the mother showed me how she usually breastfed, she was careful to have the baby's lips flanged. However, when we can see a baby's lips like this we know that there is not enough nipple and breast tissue being drawn up deeply into the baby's mouth, which creates breastfeeding problems for many. If there are any breastfeeding problems at all (and we know there were with this baby because he was referred for the frenotomies), a gestalt intervention is required - so that the baby achieves a wonderful, deep face-breast bury and the lips can't be seen at all.
Selected references
Baxter R, Merkel-Walsh R, Lahey L. The buccal frenum: trends in diagnosis and indications for treatment of buccal-ties among 466 healthcare professionals. Journal of Oral Rehabilitation. 2023:DOI: 10.1111/joor.13609.
Douglas PS, Cameron A, Cichero J, Geddes DT, Hill PS, Kapoor V, et al. Australian Collaboration for Infant Oral Research (ACIOR) Position Statement 1: Upper lip-tie, buccal ties, and the role of frenotomy in infants Australasian Dental Practice. 2018;Jan/Feb 144-146.
Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Midwifery. 2018;58:145–155.
Fraser L, Benzie S, Montgomery J. Posterior tongue tie and lip tie: a lucrative private industry where the evidence is uncertain. BMJ. 2020;371:m3928.
Kinney R, Burris RC, Moffat R, Almpani K. Assessment and management of maxillary labial frenum - a scoping review. Diagnostics. 2024;14(1710):https:// doi.org/10.3390/diagnostics14161710.
Kummer AW. Ankyloglossia: misinformation vs. evidence regarding its effects on feeding, speech, and other functions. Journal of Otolaryngology - ENT research. 2024:DOI: 10.15406/joentr.12024.15416.00552.
Kotlow L. Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. Journal of Human Lactation. 2013;29:458-464.
Mercer NSG. Posterior tongue tie and lip tie - division of tongue tie: an assault on a baby. BMJ. 2021;372(n11).
Mills N, Lydon A-M, Davies-Payne D, Keesing M, Mirjalili SA, Geddes DT. Imaging the breastfeeding swallow: pilot study utilizing real-time MRI. Laryngoscope Investigative Otolaryngology. 2020;5:572-579.
Nakhash R, Wasserteil N, Mimouni FB, Kasierer YM. Upper lip tie and breastfeeding: a systematic review. Breastfeeding Medicine. 2019;14(2):83-87.
Shah S, Allen P, Walker R, Rosen-Carole C, McKenna Benoit MK. Upper lip tie: anatomy, effect on breastfeeding, and correlation with ankyloglossia. Laryngoscope. 2020:doi:10.1002/lary.29140.
Thomas J, Bunik M, Holmes A. Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report. Pediatrics. 2024;154(2):e2024067605.
Towfighi P, Johng SY, Lally MM, Harley EH. A retrospective cohort study of the impact of upper lip tie release on breastfeeding in infants. Breastfeeding Medicine. 2022:doi:10.1089/bfm.2021.0140.
