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What's the 'deal' with Reformation?

What is the 'deal' with REFORMATION?

The term 'reformation' can mean different things to different professionals and primary caregivers alike. Here, I will explain my understanding of this term.

It is important to understand that different practitioner's and healthcare professionals will have slightly varied versions to my own, it does not mean that they are wrong, just that unfortunately there is no universal definition in correlation to a tongue tie release.

Reformation; also known as 're-occurence', re-adherence', 're-growth' or 're-attachment'

A survey conducted by the Association of Tongue Tie Practitioners in the UK published to its members in 2021, found that out of a total of 9365 total frenulotomy procedures, 3.03% patients required a second divide.

Now, there may be a number of reasons why a second frenulotomy procedure is required, and similarly it may be that not all primary caregiver's of the infant with reformation would come forward to arrange a reassessment so this figure could potentially be higher for those that are unknown, but this figure does fall inline with the global average figure so is a good base line. Your individual chosen practitioner may do their own audit on their annual reformation rate too, but that said; it is not technically a reflection on their ability, reformation has many causes of which Mother Nature is more to blame than individual practitioner accountability.

It is important to note that it is entirely NORMAL ANATOMY to have a visible frenulum, both before AND AFTER a frenulotomy (tongue tie procedure). Everybody has one, we all need one, they are all just placed at different points so some are more visible than others.

The question at any stage really is:

Is the frenulum causing issues with tongue function and motility?

To know this, there would be adverse feeding symptoms, which would indicate the need for further assessment.

Infant feeding is one of the hardest things the tongue will need to do in a lifetime, so please ensure that your chosen provider is a registered infant feeding specialist, who also provides some form of aftercare support you are happy with (see BLOG POST "Who can provide a tongue-tie release?")

So, 'Reformation' itself, I believe is very much an umbrella term and one of a few things can happen:

  1. Following frenulotomy procedure, feeding ability improves over time as the oral structures regain strength. Although you may see some visible frenulum once the wound has visually healed this is considered normal anatomy, this is NOT reformation and is the desired outcome.

  2. Scar Tissue: This can be fibrous and taut caused by the original division and can pose a restriction. This is not a fault of the practitioner, it is how some people heal. Mother Nature is in charge of this one. The good news though is that in time most scars do soften over time, but we are not in a position to have the knowledge of who will or won't scar. If you are aware of any family history of scarring issues, such as keloid scarring, it maybe something you wish to consider before making any decisions for initial division.

  3. It could be that there is residual tension in the body. Now there are a whole range of causes for this ranging from being engaged for too long, shape of maternal pelvis, c-section deliveries, instrumental or quick deliveries, right through to the tongue tie restriction itself. It's plausible that most infants would have a collection of reasons for tension in their little bodies, we do not believe it to be painful as many do not display signs of pain, but generally there may be a whole matrix web of tensions in different direction which is affecting the coordination and ability to feed effectively. This is usually resolved with time, changes in feeding positions and bodytherapies (such as @Baby-Myo', 'Osteopathy', 'Chiropractic' or 'Crainio-Sacral Therapy'. Some practitioners would suggest some tongue function exercises too which are also helpful (NOT to be confused with wound massage or stretches-see BLOG post "Post procedure tongue-function exercises").

  4. It may be that your chosen practitioner was not able to get all of the restrictive tissue, so an incomplete divide. This may be due to anatomical limitations or structures, blood loss etc. Historically, a full division was always determined by getting a 'diamond-esque' shaped wound, but as all anatomy is different this is not always the case. It is super important that you research your practitioner, their credentials, reputation and experience. Unfortunately, not every practitioner falls into a profession that is regulated, and others do not 'believe' in what I term 'a posterior restriction' (there is not a universally agreed definition of posterior), and so unfortunately will only divide the anterior aspect of the frenulum which may not resolve the original feeding issues.

  5. Regrowth: Some people refer to regrowth believing it is new tissue formation at the back which is restrictive. This is tricky as how someone can determine this between the other above types is complex. However, my understanding is that it is not regrowth per se. I believe this is the normal anatomy formation as described in point 1, but has been hindered in its protrusion due to bodily tensions (ie point 3).

© Diana Warren IBCLC, RGN

D-Restricted Ltd

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