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Patient Name___________________________________________ DATE: ________________ CONSENT FOR FRENOTOMYFrenotomy is simple procedure commonly performed for treatment of Ankyloglossia (tongue-tie). Your baby will be securely wrapped and his/her head gently held still. A topical numbing agent is applied. The doctor places a finger under the baby’s tongue to gain clear access. Small sterile scissors are used for the release. Your baby will be returned to you immediately following the procedure so that you can feed and comfort hiim/her. Possible complications of frenotomy include:excessive bleeding or infection Occasionally an ulcer may form that heals rapidly (usually within the week)Failure of procedure to resolve symptoms________________________________________Signature of Parent/Legal Guardian Signifying informed consent ________________________________________WitnessPROCEDURE NOTEPROCEDURE: CPT CODE 41010 Incision of Lingual Frenum; Frenotomy INDICATIONS: ICD10 Q38.1 Ankyloglossia DETAILS OF PROCEDURE: The patient was placed in the semirecumbent position. The tongue was retracted with a grooved retractor and an incision was made with sterile scissors into the area of the frenum. After the frenum was cut, minimal bleeding was noted. Care was taken to identify and not injure the Sub-mandibular ducts. The patient tolerated the procedure well and was discharged in the accompaniment of parents. The patient will be asked to return to see us as needed. EBL: 0 ml or _____._________________________________________ SignatureFrenotomyABOUTFrenotomy is a release of the thin tissue that can prohibit free movement of the tongue. This is called ankyloglossia or "tongue tie". Symptoms of ankyloglossia in an infant can include poor weight gain with difficulty breastfeeding. The mother often complains of pain during breastfeeding.PROCEDUREThe procedure is simple, and often the mother can breastfeed the infant immediately following the procedure. The frenulum is a very thin membrane with little to no sensory innervation or "feeling". The procedure usually results with little to no bleeding. Some infants may develop a white patch or eschar 1-2 weeks after the procedure during the healing process.AFTERCAREAfter the procedure the infant may return to its normal routine of feeding immediately. Call your physician if the patient has any excessive bleeding or other worrisome symptoms.Before Frenotomy After Release ................
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