DIAGNOSIS:
My baby has been carefully and I have been advised that he/she has excessive gum tissue between the lip and jaw bone (labial frenum) and /or a tight band between the tongue and floor of the mouth (lingual frenum). I understand these tight attachments can limit function during breastfeeding, speech, swallowing, TMJ function and sleep apnea.
RECOMMENDED TREATMENT
I understand the doctor has recommended a procedure to either release the tight frenum (Frenectomy) or removal of the tight frenum (Frenectomy). I understand that topical anesthetic may be administered as part of the treatment.
ALTERNATIVE TREATMENT
The alternative to laser treatment includes scalpel surgery using local anesthesia and/or sedation. The other alternative is to do no treatment. NO treatment could result in some or all of the conditions listed under "Symptoms". Advantages (benefits) of laser vs. scalpel or scissors include probability or re-healing, less bleeding, no sutures (stiches) or having to remove sutures. Disadvantages (risks) are included in the "Risks of Procedure".
RISKS OF PROCEDURE
While the majority of patients have an uneventful surgery/ procedure and recovery, a few cases may be associated with complications. There are some risks/ complications, which can include:
- Bleeding. This may occur either at the time of the procedure or in the first 2 weeks after.
- Infection
- Pain
- Damage to sublingual gland, which sits below the tongue. This may require further surgery.
- Injury to the teeth, lip, gums, or tongue
- Burns from the equipment
- The frenum can heal back and require further surgery
- Swelling and inflammation, especially of upper lip
- Scarring is rare but possible
- Eye damage if baby looks directly into the laser beam. Complete eye protection is mandatory and will be worn by baby and staff
NECESSARY FOLLOW-UP CARE
I understand that failure to follow doctors recommendations could lead to undesired outcomes, which are my sole responsibility. I will need to come to come to follow-up appointment after the procedure so that healing may be monitored and for the doctor or lactation consultant to evaluate and assess the outcome upon healing completion. Second-hand smoke may adversely affect healing and may limit successful healing. I understand it is imperative to follow the specific instructions given by doctor.
PARENT CONSENT
I acknowledge that the doctor has explained my child's condition and the proposed procedure. I understand the risks of the procedure, including the risks and my concerns have been discussed and answered to my satisfaction. I understand that no guarantee has been made that the procedure will improve the condition, taking into consideration factors such as the mother's breast (nipple) anatomy. I understand that my child may need another procedure if the initial results are not satisfactory. On the basis of the above statements, I REQUEST THAT MY CHILD HAS THE FOLLOWING PROCEDURE.