How a frenuloplasty can improve your breathing and sleep

If you could reduce your risk of stroke, diabetes, hypertension, depression, committing suicide, cancer, and all-cause mortality, would you do it?

If so, there might be one impactful fix you ought to pursue:

Do everything in your power to improve your sleep.

Sleep disturbances, disorders, and insomnia have been linked to all of the aforementioned problems^1-4. 

Think about your clients who struggle with these issues. Could improving sleep hygiene and providing proper medical attention to sleep disorders maximize your client’s health and longevity?

That’s partly why I have been on a sleep kick over the last couple of years. Minor tweaks in this domain have led to drastic changes for my clients and myself. 

Unfortunately, simple fixes oftentimes aren’t enough. Certain impairments and disorders may go beyond conservative measures. Left unaddressed, the consequences of poor sleep may manifest, and they are dire.

Partly, I’ve tried to improve my sleep to better educate clients who may need to travel a similar path. 

But it’s also personal.

Why am I trying to maximize my sleep?

I don’t speak much about me, but here it seems warranted.

My mom never had any major health issues and was working on taking care of herself. She was going low carb at the time and lost a bunch of weight. She looked good, felt good, and was crushing it at work. 

Until that phone call came.

My mom called our house and said she had a major headache and needed help. We went to pick her up and take her to the hospital. By the time we got to her car, the ambulance was already there.

That was the last time I heard her voice.

She ended up dying that night from a brain aneurysm. She was 49 years old.

Seeing a life end so quickly, the effects my family suffered and realizing I would now be at risk, I wanted to do all I could to prevent a similar fate. 

But I was a young, naive high schooler who knew nothing. I stayed physically active and drastically changed my diet, but I noticed my sleep quality worsen as I got older. 

I don’t think my sleep had ever been bad per se. I remember as a kid I would sleep for countless hours and feel refreshed. Then I stopped dreaming, then I slept fewer hours, then I woke up tired. It especially took a nosedive with the intense sleep deprivation I had in the D-league, despite the damage control efforts we took. 

Knowing the negative repercussions of poor sleep, I knew I had to make some changes.

How have I tried to improve my sleep?

I’ve tried a few different things that improved my sleep in a roundabout way. Let’s go down the journey.

Oral appliance and glasses

I went to the Hruska Clinic to do the Prime program back when I was into PRI (you can read about my experience in parts 1, 2, 3, and 4). 

I was dealing with some recurrent neck tension, mobility restrictions, and difficulty concentrating with reading. I thought going this route may help.

In the beginning, I got some pretty solid changes. I was able to complete a near-full squat for the first time ever, had reduced neck strain, and better reading concentration. I also had some pretty wild changes in my heart rate variability. 

During this phase of my life, I didn’t think much about my sleep quality not being that great, though I wonder if the reduced focus was contributed by that? So then why is this part of the story relevant?

The answer, folks, is because getting treated here led me to my next intervention.

Wisdom teeth extraction

Though better, my neck tension still persisted. When I got treated by Ron, he noticed I had minimal mandibular trusion available. Sadly, this was because my wisdom teeth were blocking the movement. 

In order to get that motion freed up, these puppies would have to get pulled. 

So I went to a dentist who I worked with so I could get the hookup. This experience had pros and con’s.

Con: The girl who was giving me an IV stabbed me several times on both arms before getting it to stay in the vein

Pro: I got to listen to 2pac before I went under. Also, this happened: 

After I healed up I definitely had more mandibular motion which was good. It didn’t really seem to have any impact on sleep, however. 

Sleep hygiene 

Zac, why didn’t you do this stuff sooner? WTF?!?!?!?!!

My sleep hygiene was hit or miss until I was in the NBA D-League. That’s because it was the only way I’d survive the season.

The D-league doesn’t get fancy planes and swanky hotel rooms. All our travels were commercial flights, leaving between 5 and 7 am every morning. When you play games at night and don’t get to the hotel room until 11 or 12, you do all you can to polish the proverbial turd. 

Things I did to make sure my sleep hygiene was up to snuff included:

• Blue blocking glasses
• Keeping my room cold at night
• Blacking out my curtains

I’ve done fairly well carrying these habits beyond my time in the NBA, though I am unsure to what extent it has helped my sleep quality.  

Septoplasty with turbinate reduction

When I lived in Arizona and got some imaging from my dentist, we saw some funky stuff in my nose that made me hook up with an ENT.

Per imaging, I had a sizable deviated septum with enlarged turbinates. I also had some cysts/congestion in my sinuses. These findings would impact my ability to nasal breathe. It now made sense why I always felt stuffy and got frequent colds as a kid.

The first line of defense was to see if I had and could clear up any allergies I had. I tried hormetic droplets, which did a whole lot of nothing. 

From there, I was going to get surgery, but then the NBA happened. 

Thank God I waited.

The initial plan was to leave the septum untouched, take out a turbinate, and clean out my sinuses. 

The doctor I worked with in Memphis said this was a horrible idea. Evidently, if you take out a turbinate, the anatomical nasal change can create a condition called “empty nose syndrome.” This issue basically means that you have the same (or worse) symptoms, despite having a clear nasal passage. No Bueno.

My Memphis doc told me that my deviation was pretty significant, so the fix was to shave the septum down, make the turbinate smaller, and not touch the sinus cysts (evidently these are normal and would grow back). To make the turbinate smaller, the doc told me I got the equivalent of liposuction for my nose, hence why my nose is so skinny now 😉 

Plus, you get another amazing post-surgical video. Notice how automatic my knowledge of pain biology is:

Out of all the things I tried up to this point, this surgery led to the most significant and lasting changes. Despite having an endurance athletic background and doing tons of cardiovascular work, I couldn’t get my resting heart rate to drop.

Within two weeks post-surgery, my resting heart rate dropped 10 beats per minute. No changes in training, nothing. It was dramatic.

I was able to breathe through my nose clearly for the first time IN MY LIFE. 

It was such a weird feeling to intake that much air. Over the years, my cold frequency and stuffiness dramatically reduced. I’m really glad I had this procedure.

Surprisingly, I still breathed loudly through my nose. Though I ended up doing something else that was able to improve that impairment significantly (stay tuned).  

Current sleep status

It had been a few years since I attempted anything dramatic to improve my sleep, yet living that travel PT lifestyle correlated with my sleep getting worse and worse. 

What do I mean by worse? My sleep duration shrunk (always waking up at 6-7 am, I’m more of a night owl) and per Oura Ring, REM sleep was not happening. I was waking up tired most mornings. Not fun.

I think there were a few reasons why this was the case. I was living with random roommates, which led to some stressful conditions, and I had to get up WAY early to get to work. At least early for me. Couple that with working way too much, and you start getting sleep problems.

Since settling down wasn’t in the cards, I was open to trying just about anything to get my sleep on fleek.

What led me to consider a tongue tie surgery?

It was summer of 2018, Indianapolis. I was taking the first iteration of Daddy-O Pops Bill Hartman’s Intensive.

One of my dear friends and colleagues, Joe Cicenelli, was there. He’s been in the upper airway game for a hot minute at his spot in San Francisco, both with patients and himself.

You can imagine that shit we do at these types of seminars. It inevitably turns into nerd experiments on one another. #lame. 

He performed a quick orofacial evaluation to see what was “under the hood” so-to-speak, and what ya boi might need if I were to go down this path. 

He noted that I may have a tongue tie restriction and that my palate was narrow. Regarding the tongue tie, he thought having a tongue tie release (frenuloplasty) would be money for me. He wanted me to consult with his ENT to learn more.   

Considering the sleep issues, mouth breathing, crowded mouth, and neck tension, I channeled my inner Doc Brown:

“Well, I figured, what the hell.” ~Doc Brown

I was living in California at the time, and it turns out the guy for all things tongue-tie lives in LA. #winning.

Who is that guy? Dr. Soroush Zaghi. He’s an ENT who runs The Breathe Institute in Los Angeles, a place that specializes in all things upper airway. He’s considered the best at his craft.

I consulted with him via ZOOM a couple of months after meeting with Joe. He stated that my nose seemed good, but I likely had a Grade II posterior tongue tie restriction.

For those who don’t know, there are four grades of tongue ties. Mandibular opening range of motion is compared to the same movement with both the tongue tip on the back of the top teeth and the entire tongue (the cave) on the roof of the mouth. Grades III and IV are certainly surgical candidates, grade I can usually improve with conservative measures, and grade II (ya boi) could go either way.

As for the tongue tie location, anterior tongue ties are close to the tip of the tongue and are the classic ones that you may be aware of. These are definite surgical candidates.

Posterior ties are further back on the tongue, which is what I had. 

Though he couldn’t guarantee success, he thought that I would have a pretty good outcome with the surgery. Given the relatively low cost, low risk, and potential reward, I decided to get ready for it. It was September 2018, and surgery was scheduled for January 2019. LET’S GO!!

How did I prepare myself for a good surgical outcome?

In order for the surgery to be successful, you need to put in work ahead of time. That includes maximizing what range of motion and motor control you can out of your tongue. This part is essential, as you have to place your tongue into particular positions while the surgery is being performed.

If you don’t get enough motion taken care of, Zaghi will turn you down for surgery….NO PRESSURE!!!!!

I was fortunate to have Joe run me through a bunch of different moves to prep for surgery. Here were my five moves:

The tick-tock clucks, which work on tongue suction and facial mobility:

Chopstick curls, which improve sagittal tongue motion:

Taco tongue, which improves lateral tongue mobility:

Caves, which aid in tongue suction and posterior tongue mobility:

and cheek punches, which work on rotational tongue mobility:

I hit these up three times per day. 

Right before surgery, I hopped on another Zoom call with Zaghi. He checked my tongue motion and said that it looked like I was ready to rock.

What was the surgical procedure like?

Luckily, Dr. Zaghi was doing some special guest surgeries in Redding, CA, a couple of hours from me. I drove in the snow to try and get there as quickly as possible. It was go-time!

Upon his in-person evaluation, he re-graded me. He determined that I had a grade III restriction who was compensating to look like a grade II. That means that in order for me to attain the motion that I had, I was elevating the mouth floor to move my tongue. Ideally, your tongue ought to be able to position without this compensation. 

Surprisingly, the surgery was relatively painless. The only discomfort I felt was the initial needle prick of local anesthetic. From there, I could just feel Zaghi moving my relatively lifeless tongue. It was weird.

I felt a dull sensation under my tongue from the initial cut. Then, I started to hear it:

Pop, pop, pop. 

Zaghi primarily uses a blunt dissection to separate as much fascia as possible from the tongue underside. The pops were connective tissue breaking apart near my frenulum. The further back he can go, the more motion I could potentially have. 

After getting the essential diamond-cut needed for a successful surgery, he sewed me back up and had me assume the tongue postures from the initial consult. 

Though it felt weird moving my tongue, I was blown away by my initial motion changes! 

My tongue and jaw movement felt so much freer. After a long drive home the same day, I was juiced up to begin the healing process.

How was recovery from surgery?

After surgery, I didn’t really feel a whole lot of pain unless I stretched my tongue too far. I definitely had swelling and couldn’t move my mouth too much, but I was able to return to work a couple of days later.

My diet was pretty much ice cream and smoothies initially, introducing solid foods four to five days out. 

Believe it or not, you can get sick of ice cream. I was devastated. Fortunately, I’ve recovered from this malady.

Joe and Zaghi had me do a few light tongue movements and passive stretches initially, progressing to many of the moves noted on this playlist of my YouTube Channels.  

These activities improved my motion, tongue control, and reduced excessive surgical scarring.

What have been my results from the surgery?

The results were interesting over time. The changes weren’t as dramatic as when I had my septoplasty, but there were quite a few changes as I healed and progressed in myofunctional therapy.

First, you’ll notice how my range of motion compares to pre-surgery:

Cool, so what? What tangibles does better tongue mobility get me?

Well, these fam:

• Better self-reported sleep quality, but no notable changes per Oura ring
• Significantly reduced neck tension. Now I only really have neck pain if I’m sitting at dinner talking to someone 
• Felt tongue plastered to the roof of the mouth upon awakening
• More consistent nasal breathing while sleeping
• Less feeling like pills would get stuck in my throat. I noticed this a lot with pre-surgery
• Better kissing skills (At least I tell myself that)

Clearly, I had positive changes from this surgery. Unfortunately, I was still waking up earlier than I should’ve, and the neck pain while sitting was still pretty damn uncomfortable. 

So does that mean the surgery didn’t work? Was it worth getting ya tongue cut Big Z?

I still say the surgery was a success!

As I learned afterward, there is a big reason why my changes were subtle. It turns out the tongue-tie release was an integral part of a much longer process I must undergo. Though my tongue motion is great, there was something in the way.

What is my block? Stay tuned 😉 

Sum up

I strongly recommend if you have a tongue restriction, consider getting checked out by a professional. If you have the funds or are on the west coast, definitely check out Dr. Zaghi.

To summarize:

• Tongue restrictions can impact many things upper airway
• In certain cases, a frenuloplasty can alleviate upper airway symptoms
• Ya boi had several positive changes from the procedure
• Though not completely fixed, a tongue tie release may be an integral part of a much larger plan for improving upper airway

References

1. Osman et al. Obstructive sleep apnea: current perspectives. 2018. Nature and Sci Sleep;10:21-34. 
2. Marshall et al. Sleep apnea and 20-year follow-up for all-cause mortality, stroke, and cancer incidence and mortality in the busselton health study cohort. 2014. J Clin Sleep Med;10(4):355-62.
3. Rod et al. Sleep disturbances and cause-specific mortality: results from the GAZEL cohort study. 2011. Am J Epidemiol;173(3):300-309. 
4. Alexiev et al. Sleep-disordered breathing and stroke: chicken or egg? 2018. J Thorac Dis;10(Suppl 34):S4244-S4252.