Provider PLUS Tool

by Justin Roche, MB ChB, MRCPCH, IBCLC

It is widely accepted that when choosing a service for division of tethered oral tissues the number one consideration is the experience of the provider.

I agree.

However, do babies not deserve an experienced provider AND the optimal tool?

Given that advanced technology is available to us we should embrace it. Move forwards and always strive to achieve better.

When looking at surgery we want a tool that offers the following;

• Precision of surgical technique
• Post-operative comfort
• Optimal outcome

Following release of a tongue tie the most important immediate effect we need is best function. Keeping the tongue moving, and with the greatest range of movement, is imperative.

The number one inhibitor of free movement is pain.

The greatest cause of pain post-surgery is inflammation.

Therefore, the tool which causes the least inflammation is the obvious choice.

We give analgesia to all patients however young, both before the procedure (topically) and in the days following surgery (orally or rectally), but not because using a laser causes more pain than scissors. We prescribe analgesia because all surgery causes post-operative discomfort at some level. CO₂ laser causes the least^[1,3] but we don’t want our patients experiencing any discomfort. This is the kindest approach and the one which impedes function the least. Therefore, outcome will be better.

Other advantages that the CO₂ laser offers is a bloodless field during surgery. This allows excellent vision throughout the procedure. It is this as well as the facility to alter the settings on the laser that allows precision both in terms of the width and the depth of the release down to the appropriate fascial layer.

When the wound heals there is less myofibroblast activity and less collagen^[2,4] laid down in CO₂ wounds compared to traditional scissors or scalpel wounds which is important when considering the pathophysiology of reattachment (this will be expanded on in a future post).

No-one deciding on surgery should have to compromise. Patients deserve the best care available.

If you’re interested in some of the finer details of laser physics keep reading;

NOT ALL LASERS ARE CREATED EQUAL

Whilst most people would regard all lasers as the one in the same there are many differences between the different frequency of lasers and how they interact with the tissues of the body. It is this tissue interaction that determines which is the best laser to use for any given application.

The lasers typically used for tongue tie divisions are either diode, erbium or CO₂ lasers.

• DIODE lasers are relatively cheap and are portable with many fitting into a briefcase and some just a little larger than a pen. Their interaction is with soft tissue only (gums and skin). However, their absorption in the tissues is low, unless highly pigmented, so the laser energy travels far into the tissue. To make a diode laser able to cut the tissue it is necessary to trap the laser energy in the tip of the fibre by ‘blackening’ the tip. This causes the tip of the fibre to heat up and it is this heat that cuts the tissue. As a result of this there is very little difference between one diode laser frequency and another.
• ERBIUM lasers have excellent cutting properties in both soft tissue and hard tissue (teeth). This makes this laser frequency attractive to dentists as the can use it instead of a drill for some procedures. As the laser energy at this frequency is very well absorbed in the soft-tissue they don’t coagulate the blood vessels as well so it is possible for there to be some bleeding during procedures. There is usually also water sprayed into the site during procedures to help with cooling of the tissue.
• CO₂ lasers come in two frequencies 9,300 nm and 10,600 nm. The 9,300 nm frequency has an action on both soft and hard tissue. At present this can only be used with an articulating arm. The 10,600 nm frequency is absorbed in soft tissue only and has a coagulation depth just slightly deeper than the cutting depth. This makes it both efficient at cutting whilst making the surgery bloodless. Using a SuperPulse mode means that there is no charring as the tissue can cool down between pulses. The disadvantage of the CO₂ laser is that it is only transportable within a facility due to its’ size and the cost which is significantly higher than a diode laser.

References

1. Haytac MC, Ozcelik O. Evaluation of patient perceptions after frenectomy operations: a comparison of carbon dioxide laser and scalpel techniques. J Periodontol. 2006;77(11):1815-1819.
2. Ben-Baruch G, et al. Comparison of wound healing between chopped mode – SuperPulse mode CO₂ laser and steel knife incision. Laser Surg Med. 1988;8(6):596-9.
3. Chiniforush N, et al. Treatment of Ankyloglossia with Carbon Dioxide (CO₂) Laser in a Paediatric Patient. Journal of Lasers in Medical Sciences. Vol 4. Num 1. Winter 2013.
4. Hendrick DA, Meyers A. Wound Healing after Laser Surgery. Otolaryngol Clin North Am. 1995 Oct;28(5):969-86.

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About the Author

Dr. Roche practices paediatrics at the National Tongue Tie Centre in Clonmel, County Tipperary, Ireland.

My interest in Tongue Tie dates back to 1999 when my first daughter was born. At 5 days old, having lost over 10% of her birth weight, we were fortunate enough to be able to call on the services of Carolyn Westcott, Lactation Consultant at Southampton, who diagnosed a tongue tie which was divided the same day by Paediatric Surgeon, Mr Mervyn Griffiths. Six children and four tongue ties later, I then returned to Southampton to be officially trained by Mervyn and Carolyn to divide tongue ties myself. I have been dividing tongue ties since 2008 and running a dedicated tongue tie clinic since 2010 and assess and divide tongue ties +/- lip ties in over one thousand babies each year.

I believe that every mother should have the opportunity to breastfeed her own child and enjoy the experience without pain and discomfort. As a Paediatrician, I also understand the importance of doing everything we can to improve breastfeeding rates in Ireland and therefore the long-term health of our population. Every breastfeed makes a difference.

I qualified from Leeds in 1996 already having decided that paediatrics was the path for me. I was fortunate enough to be able to get one of the first house officer (intern) jobs in Paediatrics in Leeds before moving onto SHO rotations initially at St Mary’s, Isle of Wight and then at the Southampton Hospitals group. I started my specialist registrar training at Coventry followed by Birmingham Children’s Hospital. As a family we then relocated to Ireland and I completed my higher specialist training between Sligo General Hospital, Crumlin Children’s Hospital and The National Children’s Hospital, Tallaght. As a Consultant Paediatrician I have worked at the National Children’s Hospital, Tallaght and Sligo General Hospital before taking a permanent position at South Tipperary General Hospital in March 2009.

I have Membership of the Royal College of Paediatrics and Child Health (MRCPCH) and have registration with the Medical Council (Number 171584) under the Specialist Division for Paediatrics.