Surgical risks of infant scissor frenulotomy

Scissor frenulotomy is a brief procedure used to divide a restrictive lingual frenulum beneath an infant’s tongue. It has been performed for many years, and serious complications appear uncommon. However, no procedure is entirely without risk, and families need balanced information before deciding whether it is appropriate for their baby.

This article focuses on simple scissor frenulotomy in infants under 12 months of age, or before the upper teeth erupt if that happens sooner. It does not cover laser procedures, more extensive oral surgery or procedures undertaken in older children.

The decision to divide a tongue-tie should follow an assessment of feeding function, not appearance alone. A visible frenulum does not automatically mean that it is restricting tongue movement or causing feeding difficulties. As the saying goes, anatomy provides information; function provides context.

Families may find it helpful to read Surgical release or conservative management for my baby's tongue-tie alongside this article.

What the evidence tells us

The National Institute for Health and Care Excellence (NICE, 2005) concluded that the evidence available at the time was adequate to support the use of division of tongue-tie in infants with breastfeeding difficulties, provided normal arrangements were in place for consent, audit and clinical governance. NICE also recognised that complications were possible.

A Cochrane review by O’Shea et al. (2017) examined five randomised controlled trials involving 302 infants. The trials did not report excessive bleeding, infection requiring treatment or damage to the tongue or submandibular ducts. The absence of a reported event in these studies does not prove that the risk is zero.

A different source of information is the Association of Tongue-tie Practitioners (ATP) audit published in 2025. It received 46 responses covering 8,061 procedures. Respondents reported five ambulance calls, approximately 0.06% of the procedures represented in the audit, four cases of bleeding requiring medical intervention and one hospital transfer. No confirmed infections were reported by respondents.

These figures are useful for understanding the experiences reported by participating practitioners, but they should not be interpreted as a complete national complication rate. The audit was voluntary, relied on practitioner responses and cannot capture every procedure or every complication. Submission of data by all practitioners and NHS services is not mandatory, so complete national figures are not available.

Bleeding

Bleeding is an expected potential risk when tissue is divided. The amount varies between infants, and most bleeding following a simple scissor frenulotomy is limited.

In a case series of 215 infants, Griffiths (2004) reported no bleeding in 84 infants (39%), a few drops in 113 (53%) and a small amount in 18 (8%). None of the infants needed pressure applied for as long as one minute to control the bleeding, and no delayed primary or secondary haemorrhage was reported. These findings are reassuring, although they cannot guarantee that every infant will have the same experience.

A simple frenulotomy divides the lingual frenulum in the midline. It is not intended to divide the lingual arteries. Nevertheless, the floor of the mouth contains blood vessels, and significant bleeding, although uncommon, can occur.

Vitamin K and blood clotting disorders

Vitamin K is essential for normal blood clotting. Newborn babies have naturally low vitamin K stores, which is why vitamin K is routinely offered after birth to prevent vitamin K deficiency bleeding (VKDB). Babies who have not received vitamin K, or whose course is incomplete, may be at increased risk of serious bleeding after a procedure.

Inherited or acquired blood clotting disorders can also increase the risk of bleeding. These include conditions affecting clotting factors, such as haemophilia, and disorders affecting platelets or their function. Some conditions may not have been diagnosed in an infant before their first procedure. A family history of unusual or prolonged bleeding, excessive bleeding after surgery or dental procedures, or a known bleeding disorder should therefore be explored during the pre-procedure assessment.

A baby can appear healthy and still have an underlying clotting disorder. Where there is a known or suspected bleeding disorder, or uncertainty about vitamin K prophylaxis, the practitioner must assess whether it is safe to proceed and seek appropriate medical advice where necessary. The procedure should not go ahead until any relevant risk has been adequately addressed.

Read more in Vitamin K and Tongue-tie Division and Blood clotting disorders and Tongue-tie division.

Delayed or persistent bleeding

Bleeding can occasionally begin or recur after the infant has left the clinic. Disturbance of the wound may contribute, but persistent bleeding should not automatically be attributed to normal healing or to the infant crying.

Families should receive clear, written instructions about what to do if bleeding occurs, including how to contact the practitioner and when to seek emergency help. The ATP has published bleeding management guidance, including guidance on prolonged bleeding.

If bleeding continues or cannot be controlled after the advised measures have been followed, urgent medical assessment is needed. If bleeding is persistent or uncontrolled, families should call 999. The purpose of this advice is not to suggest that a small initial amount of blood is an emergency, but to ensure that a rare serious complication is not overlooked.

Pain

Pain during and after infant frenulotomy is difficult to measure because babies cannot describe their experience. Crying is one possible response, but it does not provide a precise measure of pain intensity.

In Griffiths’ (2004) study, 39 of 215 infants (18%) slept throughout the procedure. Sixty per cent cried more during or after division, with the average period of increased crying reported as 0–15 seconds. Eighty-five per cent cried for 20 seconds or less, while two infants cried for more than one minute. The study did not use an anaesthetic or analgesic. These findings describe the responses seen in that particular group; they do not establish that every infant experiences the procedure in the same way.

Anatomical research by Mills et al. (2019), identified branches of the lingual nerve close to the surface of the underside of the tongue, with small branches extending towards the frenulum. This demonstrates that sensory nerve structures are present in the region. It does not tell us precisely how much pain an individual baby experiences during a brief division, nor does it establish that the frenulum lacks pain sensation.

Some infants settle quickly and appear comfortable after the procedure. In others, swallowed air (aerophagia) may accumulate throughout the day, contributing to discomfort that becomes more noticeable during the evening ‘witching hour’. This may be mistaken for pain from the healing wound, when trapped gas could instead be contributing to the infant’s unsettled behaviour.

Pain relief should be discussed with the practitioner, taking the infant’s age, weight and individual circumstances into account. Paracetamol may be appropriate for some infants when they are old enough and it is given in accordance with the relevant product instructions and professional advice. Ibuprofen is not suitable for all infants, particularly very young or low-weight babies, and should only be considered when age and other eligibility criteria are met.

The ATP’s position statements provide further guidance on frenulotomy in different age groups. The practitioner should explain the approach to comfort and pain relief before consent is given.

Injury to surrounding structures

The floor of the mouth contains delicate tissues, blood vessels, nerves and salivary ducts. Accidental injury to the tongue or surrounding structures is a recognised but apparently rare complication of infant frenulotomy. However, available studies are too limited to establish a reliable risk percentage specifically for simple scissor division. In a Cochrane review, no damage to the tongue or submandibular ducts was reported among 152 infants who underwent frenotomy in the relevant trials, but these numbers are too small to exclude rare injuries.

NICE identifies damage to the tongue and the submandibular ducts as possible complications. The submandibular ducts carry saliva into the mouth. Damage to surrounding structures is not a common finding in the small randomised trials reviewed by Cochrane, but those trials were also not large enough to exclude rare injuries.

The practitioner's training, experience, knowledge of anatomy and ability to recognise when a procedure is inappropriate are important safeguards. Families should be able to ask about the practitioner's qualifications, experience, clinical governance and arrangements for managing complications.

Infection

Any procedure that breaks the skin or mucosal surface carries a potential risk of infection. The mouth contains many microorganisms, but this does not mean that infection will necessarily follow a frenulotomy.

The ATP's 2025 audit covered 8,061 procedures, with no confirmed infections reported. However, participation was voluntary, and the audit relied on information submitted by respondents. This finding should therefore not be interpreted as proof that infections never occur or as a definitive national infection rate.

Wound healing and reformation

After a simple scissor frenulotomy, the wound is generally left open to heal naturally. Stitches are not routinely used. A pale cream or yellow-white appearance can develop over the wound as part of normal healing. It may look like an ulcer or a layer of material over the tissue, but its appearance alone does not establish that infection is present.

The healing process and the appearance of the wound are explained in more detail in Wound healing in infants after a tongue-tie release.

It is important to distinguish between different outcomes during and after healing:

• Normal healing: the wound changes in appearance as the surface heals. A pale cream or yellow-white coating forms and does not, by itself, indicate infection.

• Reformation or readherence: as the wound heals, tissue may reconnect across the divided area, potentially restricting tongue movement again.

• Residual restriction: some restriction may remain following division. The significance of this depends on the infant's tongue function and feeding, rather than the appearance of the wound alone.

• Thickened or hypertrophic scar tissue: scar tissue may become raised or thickened during healing. Its presence does not automatically mean that tongue function is impaired, but where movement or feeding is affected, further assessment may be appropriate.

These outcomes are not interchangeable. The appearance of the healing wound alone cannot establish whether restriction has returned, whether scar tissue is affecting movement, or whether the infant's functional difficulties have another explanation.

These are not interchangeable explanations, and a wound's appearance cannot by itself determine which has occurred.

The ATP has discussed reformation and aftercare in its position statements. Its published estimates have placed reformation at around 2–4%. This is an estimate, not a guaranteed rate for an individual practitioner or baby. Rates from international studies may not be directly comparable because populations, definitions, aftercare practices and techniques differ, including the use of laser and other instruments.

Wound management and tongue function

Wound stretching or deliberately disrupting a healing wound is different from supporting normal tongue movement and function. The ATP has a position statement on disruptive wound management. Families should receive clear advice from their practitioner about what is recommended and what should be avoided.

Feeding itself involves tongue movement. Some infants may also benefit from appropriate tongue-function activities, where these are indicated and taught by a suitably qualified practitioner. Such activities should not be confused with forcibly reopening a wound.

Further reading includes Beyond the tongue-tie release: why aftercare matters. Any exercises should be appropriate to the individual infant and should not be painful or coercive.

Repeat procedures

Some infants undergo a second procedure because a restriction remains, function has not improved sufficiently, or tissue has reconnected. A repeat procedure should not be an automatic response to ongoing feeding difficulties.

Before considering further division, the practitioner should reassess tongue function, feeding, healing and the original indication for treatment. Other factors may be contributing, including feeding mechanics, oral-motor difficulties, tone, positioning, milk flow or the need for further feeding support.

Repeatedly cutting tissue, particularly where scar tissue has developed, may not resolve the underlying problem and can potentially make matters more complicated. The decision should be based on a fresh assessment of the likely benefit and risk, rather than the assumption that more division will produce a better result.

When feeding does not improve

A frenulotomy does not guarantee that feeding difficulties will resolve. Some families notice a change quickly, while other infants need time, feeding support and opportunities to develop more effective movement and coordination. Muscles and feeding skills do not necessarily change immediately after a restriction is released.

If there is little or no improvement, the practitioner should be informed so that progress can be reviewed. It is important to revisit the original concerns and consider whether the frenulum was the main cause, whether the division has achieved its intended functional outcome, or whether another factor needs attention.

Manual bodywork or other supportive approaches may be considered where appropriate, but they should not replace a proper reassessment of feeding and oral function. Families should not be left to assume that persistent difficulties mean they need another procedure.

Further reading includes Bottle-feeding with a restriction, Beyond the tongue-tie release: why aftercare matters and Tongue-tie research: the evidence 2026.

Making an informed decision

Simple scissor frenulotomy is usually brief, and the available evidence suggests that serious complications are uncommon. However, small trials and voluntary audits cannot provide a precise estimate of every possible risk, all of which need to be discussed honestly. Families who would like to understand more about the instruments and techniques used can read How is a tongue-tie release performed in infants?.

The decision should balance the infant’s current functional difficulties, the likely benefit of division, the alternatives and the risks of proceeding. It should also take account of the practitioner's assessment, the family's priorities and the support available afterwards. Understanding the differences between procedural approaches may help families make an informed decision; further information is available in Surgical release or conservative management for my baby's tongue-tie.

Consent is meaningful when families have time to ask questions, understand the uncertainties and make a decision without pressure. Choosing not to proceed immediately, or deciding to continue with conservative feeding support, can be reasonable when the expected benefits are uncertain or the assessment is incomplete.

The aim is not simply to divide a visible piece of tissue. It is to help an infant feed and function more comfortably, while avoiding unnecessary intervention and ensuring that any procedure is undertaken with appropriate skill, consent and follow-up.

References

Academy of Breastfeeding Medicine (2021) ‘Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads’. Breastfeeding Medicine, 16(4), pp. 278–281. https://doi.org/10.1089/bfm.2021.29179.ylf

Association of Tongue-tie Practitioners (ATP) (2022) Position statement on disruptive wound management. Available at: https://www.tongue-tie.org.uk/position-statements

Association of Tongue-tie Practitioners (ATP) (2024) Position statement on frenulotomy (surgical release of tongue-tie) in different age groups. Available at: https://www.tongue-tie.org.uk/position-statements

Association of Tongue-tie Practitioners (ATP) (2025) Audit of tongue-tie divisions. Audit findings reported by participating practitioners.

Association of Tongue-tie Practitioners (ATP) (2026) Bleeding guidelines. Available at: https://www.tongue-tie.org.uk/bleeding-guidelines

Griffiths, D.M. (2004) ‘Do tongue ties affect breastfeeding?’, Journal of Human Lactation, 20(4), pp. 409–414. https://doi.org/10.1177/0890334404266976

Mills, N., Keough, N., Geddes, D.T., Pransky, S.M. and Mirjalili, S.A. (2019) ‘Defining the anatomy of the neonatal lingual frenulum’, Clinical Anatomy, 32(6), pp. 824–835. https://doi.org/10.1002/ca.23410

National Institute for Health and Care Excellence (NICE) (2005) Division of ankyloglossia (tongue-tie) for breastfeeding. Interventional Procedures Guidance IPG149. Available at: https://www.nice.org.uk/guidance/ipg149

O’Connor, M.E., Gilliland, A.M. and LeFort, Y. (2022) ‘Complications and misdiagnoses associated with infant frenotomy: results of a healthcare professional survey’, International Breastfeeding Journal, 17, article 39. https://doi.org/10.1186/s13006-022-00481-w

O’Shea, J.E., Foster, J.P., O’Donnell, C.P.F., Breathnach, D., Jacobs, S.E., Todd, D.A. and Davis, P.G. (2017) ‘Frenotomy for tongue-tie in newborn infants’, Cochrane Database of Systematic Reviews, 3, CD011065. https://doi.org/10.1002/14651858.CD011065.pub2

Wilson, [bibliographic details to be confirmed] (2016). Study cited in the literature on pain following infant frenotomy. Full reference requires verification before publication.