Does your baby have an upper lip-tie or buccal ties?

What do you need to know about the diagnosis of upper lip-tie?

Do babies need to flange their lips to breastfeed well?

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).

The shape of and insertions of the frenulum (that fleshy midline piece between the upper lip and gum) are highly variable. There are three photos on this page of normal labial frenula.

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 This belief comes from outdated biomechanical models, which believe that the lips have to grasp the breast or flange or turn out in a 'special K', in order for the baby to stay on the breast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.

Professor Laurie Walsh and I gathered together a team of clinicians and researchers in 2018 and published the first little article that we knew of internationally stating there was no place for labial frenotomy in infants.

Since then, in 2020, a pioneering MRI study by ENT surgeon Dr Nikki Mills confirmed in a live study of 11 breastfeeding babies that babies' lips are usually neutral (not flanged) during breastfeeding when the mother and baby don't have breastfeeding problems. The lips were not flanged or 'everted' in eight of these 11 babies.

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 during breastfeeding, she won't be drawing up large amounts of breast tissue into her mouth. For many, visible lips result 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 baby's 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, at about seven years of age, 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 teeth, called a 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!

What are the risks of an unnecessary labial frenotomy?

Labial (or upper-lip) frenotomy actually places babies at increased risk of a gap between their front teeth in later childhood and adulthood, due to the effects of scarring - not to mention unnecessary pain and risk of bleeding and infection.

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

Your baby's lips are sensitive sensory organ. But when 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 the tethering tissue which joins the cheeks to the upper margin of the gums. 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.

The baby in the photo below was given upper lip, buccal and lingual frenotomies. I was concerned by the unusual laxity of the upper lip post-frenotomies, and wondered what the cosmetic implications might be in later life. You'll 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 for 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.

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.

Keenehan K, Varavenkataraman G, Kellner CR. Trends in maxillary frenulum pathology and treatment from 2009 to 2023. International Journal of Pediatric Otorhinolaryngology. 2025;192(112335):https://doi.org/10.1016/j.ijporl.2025.112335.

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.

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.