Chronic Wound Management in Singapore
Plastic surgeon-led assessment and treatment for wounds that fail to heal
A wound that has not healed after four to six weeks despite appropriate management is considered chronic. Chronic wounds are common in patients with diabetes, reduced mobility, venous insufficiency, previous radiation treatment, or a history of surgery. This represents a significant burden on patients and carers alike. At Doctor Stitch, chronic wound assessment and management are led by Dr Ng Zhi Yang, a dual-accredited UK and Singapore plastic surgeon with specific training in complex wound care, skin grafting, and reconstructive surgery. We accept referrals from GPs and other specialists, and are also happy to see patients who self-refer. House visits for patient assessment also available on request.
Types of Chronic Wounds We Manage
1. Diabetic Foot Ulcers
Diabetic foot ulcers are among the most common and serious chronic wounds. They arise from a combination of peripheral neuropathy, vascular insufficiency, and impaired immune response, and carry a significant risk of infection, osteomyelitis, and amputation if not managed promptly and correctly.
Management requires wound debridement, infection control, offloading, and optimisation of blood glucose and vascular supply. Surgical debridement, skin grafting, and in selected cases flap reconstruction, are used where conservative measures are insufficient.
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2. Pressure Sores (Decubitus Ulcers)
Pressure sores develop when sustained pressure over a bony prominence causes tissue ischaemia and breakdown. They are graded by depth from superficial skin loss (Grade 1-2) through to full-thickness tissue loss exposing bone, tendon, or joint (Grade 3-4). Higher-grade pressure sores require surgical debridement and reconstruction, typically with a local or regional flap, to achieve durable closure over the bony prominence.
Management also addresses the underlying cause through pressure relief, nutritional optimisation, and where relevant, spasticity management. Two important complications of deep pressure sores must be actively considered. First, chronic osteomyelitis: wounds overlying bone carry a significant risk of underlying bone infection, which may be subclinical and present only as a wound that persistently fails to close despite adequate soft tissue management. MRI is the investigation of choice where osteomyelitis is suspected, and surgical management requires debridement of infected bone alongside soft tissue reconstruction. Second, malignant transformation: a chronic, non-healing or changing wound at the site of a longstanding pressure sore should be assessed with biopsy to exclude Marjolin's ulcer (see Warning Signs below).
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3. Leg Ulcers
​Venous leg ulcers arise from chronic venous insufficiency and are the most common cause of lower limb ulceration. They typically occur above the medial malleolus and are associated with surrounding lipodermatosclerosis, haemosiderin staining, and varicose veins. In some cases, the pattern is mixed, where the arterial supply or even, lymphatics are involved.
Management includes compression therapy, wound dressing optimisation, and treatment of the underlying disease. Where ulcers are large or slow to heal, split thickness skin grafting can accelerate closure. Underlying arterial and/or venous disease is addressed in conjunction with a vascular surgeon where appropriate. In chronic lymphoedema, further reconstructive microsurgery in the form of lymphaticovenous anastomosis or bypass, or liposuction, may be required and is offered through ZNG Plastic Surgery.
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4. Irradiated Wounds
Radiation causes progressive obliterative endarteritis, a gradual destruction of small blood vessels within the irradiated field, leading to tissue hypoxia, fibrosis, and impaired healing capacity. Wounds within a previously irradiated field heal poorly and are prone to breakdown after even minor trauma or surgery.
Management requires wound bed optimisation, avoidance of further tissue compromise, and in many cases reconstruction with well-vascularised tissue from outside the radiation field, typically a muscle flap with skin or skin graft, to bring healthy blood supply into the area to achieve wound healing.
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An important and under-recognised risk in longstanding irradiated wounds is radiation-induced sarcoma. This typically presents many years after radiotherapy, sometimes up to decades, as a new or changing soft tissue mass, or a wound that unexpectedly fails to heal or deteriorates within a previously stable irradiated field. Although rare, the diagnosis must be considered and excluded with biopsy and imaging in any irradiated wound that behaves unexpectedly. Early diagnosis significantly affects outcome as the condition can be lethal. Further definitive management is offered through ZNG Plastic Surgery.
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5. Post-Surgical and Post-Traumatic Non-Healing Wounds
Wounds that fail to heal after surgery or trauma may result from infection, poor blood supply, radiation damage, or underlying medical conditions. Assessment focuses on identifying and addressing the cause; treatment includes debridement of non-viable tissue, infection control, and optimisation of the wound bed, before definitive closure with grafting or flap reconstruction where required.
Warning Signs in Chronic Wounds
​Longstanding chronic wounds carry specific risks that extend beyond failure to heal. Three important diagnoses must be actively considered and excluded in appropriate clinical contexts:
(1) Marjolin's Ulcer: Malignant transformation, most commonly to squamous cell carcinoma, can occur in any chronic wound of long duration, particularly burn scars and pressure sores. It typically presents as an area that bleeds, develops an irregular raised edge, or fails to respond to previously effective treatment. The diagnosis is frequently delayed because changes are attributed to the underlying wound rather than to malignancy. Biopsy is required for any chronic wound that fails to heal, or changes unexpectedly.
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(2) Radiation-Induced Sarcoma: A rare but serious, and potentially lethal late complication of radiotherapy, typically presenting a decade or more after treatment. It should be considered in any irradiated wound that develops a new soft tissue mass, unexpectedly deteriorates, or fails to heal despite previously stable behaviour. Diagnosis requires biopsy and cross-sectional imaging with CT scans. Early diagnosis can significantly affect both wound and survival outcomes.
(3) Chronic Osteomyelitis: Deep pressure sores and other wounds overlying bone may be complicated by underlying bone infection. This can be subclinical, presenting only as a wound that fails to close despite adequate soft tissue management, or persistent discharge. MRI is the investigation of choice where osteomyelitis is suspected. Surgical management requires debridement of infected bone alongside soft tissue reconstruction.
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Dr Ng has specific training in skin cancer and soft tissue tumour surgery and manages these diagnoses through the full pathway: biopsy, imaging, surgical excision with appropriate margins, and reconstruction of the resulting defect where required.
The Role of a Plastic Surgeon in Chronic Wound Care
Chronic wound management sits at the intersection of wound care science and reconstructive surgery. A plastic surgeon brings specific skills that are not always available in standard wound care pathways:
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(1) Surgical debridement: Precise removal of non-viable tissue under appropriate anaesthesia, with preservation of healthy structures.
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(2) Wound bed preparation: Optimising the wound environment for healing or surgical closure, including management of biofilm, infection, and wound depth.
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(3) Skin grafting: Split or full thickness skin grafting to achieve rapid wound closure where conservative measures have failed or are unlikely to succeed within a reasonable timeframe.
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(4) Flap reconstruction: For wounds overlying exposed bone, tendon, or joint, or where a skin graft alone would be insufficient, local or regional flap reconstruction provides durable, well-vascularised coverage. This is managed through ZNG Plastic Surgery where day surgery or hospital admission may be required.
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(5) Malignancy surveillance: Recognition of warning signs of Marjolin's ulcer, radiation-induced sarcoma, and other wound-associated malignancies, with biopsy and surgical management where indicated.
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What Does Assessment and Treatment Involve?
(1) Initial Assessment: A focused clinical assessment of the wound is performed, including wound dimensions, depth, tissue quality, surrounding skin, and signs of infection or malignancy. Relevant investigations, including blood tests,
wound swabs, imaging, and biopsy where indicated, are arranged at or following the initial visit (clinic or house visit).
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(2) Wound Care and Dressing Optimisation: An appropriate dressing regimen is established based on the wound
characteristics. Dressing changes are scheduled at appropriate intervals with clear home care instructions between visits. Coordination with nursing or wound care staff can be arranged for, as necessary.
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(3) Advanced Wound Care Adjuncts:
Where standard dressings are insufficient, additional modalities are used to optimise the wound bed before definitive surgical closure:
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Negative pressure wound therapy (VAC therapy): Applies controlled negative pressure to the wound to reduce oedema, promote granulation tissue formation, and manage exudate. Particularly useful for large, deep, or complex wounds prior to grafting or flap reconstruction.
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Skin substitutes: Biological and synthetic skin substitutes, such as acellular dermal matrices (ADM), Integra and BTM, can be applied following debridement to prepare a wound bed that is not yet ready for direct grafting, or to provide a scaffold for dermal regeneration in complex wounds.
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Nutritional optimisation: Chronic wound healing is critically dependent on adequate nutrition, particularly protein intake and micronutrients including zinc and vitamin C. Referral to a dietitian is arranged where nutritional deficiency is identified or suspected, particularly in elderly patients or those with diabetes.
(4) Surgical Intervention: Where debridement, skin grafting, or flap reconstruction is required, this is planned and performed at the appropriate setting in clinic, day surgery, or hospital, depending on the complexity of the procedure. Hospital-based surgery is arranged through ZNG Plastic Surgery with continuity of care under the same surgeon.
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(5) Multidisciplinary Coordination: Chronic wounds frequently require input from other specialists including endocrinologists, vascular surgeons, orthopaedic surgeons, infectious disease specialists, and allied health professionals including dietitians and physiotherapists. We coordinate with your existing medical team and
GP to ensure a multidisciplinary approach to management. A referral summary or discharge letter is provided to the referring GP after each episode of care.
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Referral Information
Doctor Stitch accepts referrals from GPs, polyclinics, and other specialists for chronic wound management. Referral letters can be sent via email to doctorstitchsg@gmail.com or via WhatsApp. We aim to offer an appointment within one week of referral for stable chronic wounds, and sooner for wounds with signs of active infection or clinical concern.
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Patients who wish to self-refer are also welcome. A referral letter is not required to book an appointment.
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A referral summary or discharge letter is provided to the referring GP after each episode of care.
Pricing
Pricing varies depending on the size, location, and complexity of the chronic wound in accordance with Singapore MOH Table of Surgical Procedure (TOSP) fees. Consultation and follow-up, as well as medications and further tests (e.g. microbiology, imaging), if necessary, are charged separately. A clear cost estimate is provided before any treatment is initiated.
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Frequently Asked Questions
1. How do I know if my wound is chronic?
A wound that has not shown meaningful healing progress after four to six weeks of appropriate treatment is generally considered chronic. If your wound has stalled, is getting larger, smells, or is increasingly painful, seek specialist assessment.
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2. Can chronic wounds be treated without surgery?
Many chronic wounds can be managed with optimised dressing care, infection control, and treatment of underlying causes. Surgery is considered when conservative management has failed or when the wound is unlikely to heal without surgical intervention within a reasonable timeframe.
3. What is Marjolin's ulcer and should I be worried?
Marjolin's ulcer is a rare malignant transformation that can occur in longstanding chronic wounds, particularly burn scars and pressure sores of many years' duration. It is uncommon but important not to miss. Any wound that changes unexpectedly, particularly after years of stability, should be assessed with a biopsy. If you have a longstanding wound that has recently changed in character, mention this at your assessment.
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4. What is radiation-induced sarcoma?
Radiation-induced sarcoma is a rare but serious late complication of radiotherapy, typically presenting a decade or more after treatment as a new soft tissue mass or a wound that unexpectedly fails to heal. Any irradiated wound that deteriorates or behaves unexpectedly should be assessed with biopsy and imaging to exclude this diagnosis.
5. Do you accept GP referrals?
Yes. We welcome referrals from GPs and other specialists. Referral letters can be sent via email to doctorstitchsg@gmail.com or via WhatsApp. A discharge summary is provided after each episode of care.
6. Can I self-refer without a GP letter?
Yes. A referral letter is not required. You are welcome to contact us directly via WhatsApp to arrange an assessment.
7. Will I need hospital admission?
Most wound assessments and dressing changes are managed in a clinic or home setting without hospital admission. Surgical procedures such as debridement and skin grafting may require day surgery or hospital admission depending on complexity. Where hospital-based surgery is required, this is arranged through ZNG Plastic Surgery with
continuity of care under the same surgeon.
8. Can wounds in a previously irradiated area be treated?
Yes, but irradiated wounds require careful management. The tissue within a radiation field has compromised blood supply and heals poorly. Reconstruction typically requires bringing well-vascularised tissue from outside the radiation field. Any irradiated wound that is deteriorating or failing to heal should also be assessed to exclude radiation-induced sarcoma, which though rare, can present as a non-healing wound many years after radiotherapy.
To arrange an assessment, contact us via WhatsApp.
Same-day appointments are available subject to scheduling.
Where definitive reconstructive or complex surgery is required, care may continue under Dr Ng Zhi Yang via ZNG Plastic Surgery
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Concerned about a skin lesion within a chronic wound? See our Skin Cancer page
