Bleeding is a complication of any wound inducing procedure.  A frenulotomy procedure is not likened to a blood loss but can be small vessel or capillary related. In the majority of cases only around half a teaspoon of blood loss is expected, it is not an arterial loss, and this usually subsides immediately after the procedure through feeding, which not only provides pressure to the area to stem the bleeding, but also comfort to the infant through stimulating the sucking reflex inducing an oxytocin release. The estimated risk of continued bleeding is currently suggested to be 1:400, following pressure and feeding management, the risk further reduces to 1:7,000 for those requiring medicated buccal treatment (ATP 2017).  A further audit by ATP (2018) suggested the at the required need for medical intervention (sutures or cautery) is 1:76,764, suggesting that prolonged pressure controlling the bleeding stemmed the oozing en-route to hospital.  There is a risk of bleeding being caused by inadvertent injury to small vessels or other oral structures too, which are an anatomical anomaly and unpredictable.  These cases are believed to be few but there are no studies to suggest its incidence (and it is possible incidence is under-reported). However, the management and control of any bleed is the same regardless of the type/cause.

It is believed that infection risk to the division site is estimated at 1:12,015 (ATP Complications Audit 2022).  All surgical wounds are subject to risk of infection introduction or cross contamination, but by ensuring the practitioner uses an aseptic technique, sterile scissors and gauze, handwashing (and antibodies found naturally occurring in breast milk) all contribute to lowering its risk further.

Following a scissor divide, the wound heals through primary intention, and visually looks like a mouth ulcer.  This is part of what is considered the ‘normal’ wound healing process and gradually gets smaller before finally dissolving and dispersing into the mucosa where nothing further can be visualised, and on average takes 7-10 days.

It is not fully known if the procedure itself is painful.  However, as the infant is temporarily restrained and in a potentially unfamiliar environment, the infant may become unsettled after the procedure which may discombobulate the infant, who is then released, comforted and offered a feed.  We also know that 8% infants do sleep through the whole procedure (NICE 2005). In young infants there is usually no need for local anaesthetic and may be seen as counter productive because numbing an area results in not being able to feel a feeding -vacuum which may prolong the bleeding timeframe.  Numbing gels are believed to be ineffective as swallowed by infants rather than allowing absorption time, rendering ineffective use-but it is also unknown how a gel may react against within an open wound.

All infants vary on their behaviour/response following the division, and is influenced by many factors including: -Availability of maternal milk supply, -Timing of the previous feed, -Age/alertness of the baby, medical conditions, -Environmental factors, -Tiredness, -Hunger level.

A rare complication is the inadvertent injury from the scissors, controlled by the practitioner, to the ventral tongue surface or surrounding oral structures, which is inclusive of the salivary glands or other fragile oral structures.  The scissors do not have the strength to cut through the genioglossus muscle itself, but may damage the lip, tongue, submandibular glands or other oral structures.  Treatment would be managing blood loss, but it is not expected to impact long-term function, and this risk is further minimalised by momentary restraint of the infant.

Reformation may include a few possibilities.  As the wound edges meet through the normal stages of wound healing, they form a 'neo-frenulum'. This is normal anatomy and is not considered as reformation unless adverse feeding ability persists. Visually, it will look like there is a new frenulum-because there is - that does not mean it has reformed. It also does not technically “regrow”, but it may present restriction through residual frenula protrusion as the tongue body comes forward.  Or through wound scarring which would be restrictive through fibrous and taut formed tissue. Hazelbaker (2014) discusses how the frenulum is very much likened to ligament tissue, rather than membrane, so it would remain relative within the mouth as the infant grows. In these cases, a second scissor divide may be considered but more than that may be viewed as counter-productive (scar overlapping further scar) so in these cases referral to a specialist surgeon or dentist may be suggested.  Reformation is thought to affect 1-4% of scissor divides (NHS 2014).