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Skin Cancer Surgery
Skin cancer surgery requires both oncological and reconstructive expertise to achieve clear margins, staging the disease correctly, and restoring appearance and function after excision. I manage the complete surgical pathway as a single surgeon, from initial biopsy through to wide local excision, sentinel lymph node biopsy where indicated, and reconstruction of the resulting defect, following UK NICE, BAD and BAPRAS guidelines throughout.
My Approach
Skin cancer is not a single disease, and its management is not a single operation. BCC, SCC, melanoma, and rarer tumours each have distinct
biological behaviour, require different excision margins, and carry different risks of regional spread. Getting the management right from the outset - correct diagnosis, correct staging, appropriate margins and reconstruction planned in the context of the oncological requirements - is what determines outcome.
I trained in the UK where plastic surgeons form a core part of the skin cancer multidisciplinary team, managing the surgical pathway from biopsy through to sentinel lymph node biopsy and reconstruction as part of routine practice. This model, where a single surgeon with both oncological and reconstructive training managing the full pathway, is less established in Singapore's private sector, where these roles are often divided between dermatologists, general surgeons, and plastic surgeons without a coordinated pathway.
For straightforward cases such as a suspicious lesion requiring assessment and simple excision, same-day management is available through my other practice, Doctor Stitch. Cases requiring more extensive surgery, sentinel lymph node biopsy, or complex reconstruction are managed here at ZNG Plastic Surgery, with me as the same surgeon throughout.
Planning & Technique
My approach begins with an accurate diagnosis. Not every suspicious lesion is a skin cancer, and not every skin cancer is managed the same way. A focused clinical assessment, with dermoscopy where appropriate, establishes whether a biopsy is needed first or whether same-day excision is appropriate. Once the diagnosis is confirmed, the surgical plan is tailored to the tumour type, size, location, and stage.
Basal Cell Carcinoma (BCC)
BCC is the most common skin cancer I manage. It grows slowly and rarely spreads but causes progressive local tissue destruction if untreated. Standard BCCs on the trunk and limbs are managed with straightforward excision. High-risk subtypes - morphoeic, infiltrative, or those at cosmetically sensitive sites such as the nose, eyelids, ears, and lips - require wider margins and careful reconstruction planning. For selected cases, non-surgical options including topical Efudix, photodynamic therapy, or radiotherapy are discussed where appropriate. Recurrent or incompletely excised BCC is managed with re-excision or Mohs micrographic surgery coordination where indicated.
Squamous Cell Carcinoma (SCC)
SCC carries a greater risk of regional spread than BCC, particularly in high-risk cases. Features that define high-risk SCC include tumour thickness greater than 2 mm, poor differentiation, perineural invasion, immunosuppression, location on the ear or lip, and recurrence. These features determine the excision margins required and whether sentinel lymph node biopsy should be considered. I follow the BAD guidelines for SCC risk stratification. For SCC with confirmed lymph node involvement, therapeutic lymph node dissection is performed.
Melanoma
Melanoma is the most serious of the common skin cancers. Management follows UK melanoma guidelines, which define excision margins by Breslow thickness and include sentinel lymph node biopsy for tumours of appropriate depth as a staging procedure.
Wide local excision: Margins are determined by Breslow thickness - 0.5 cm for in situ and thin melanomas, up to 2cm for thicker lesions. The defect is reconstructed with the simplest technique that achieves a good functional and cosmetic result.
Sentinel lymph node biopsy (SLNB): For melanomas of appropriate thickness (generally Breslow >0.8mm with adverse features, or >1mm), SLNB is offered as a staging procedure. The sentinel node is identified using lymphoscintigraphy and a gamma probe, harvested, and sent for formal histological analysis including immunohistochemistry.
Lymph node dissection: Where lymph node involvement is confirmed through clinically palpable nodes, therapeutic dissection of the involved nodal basin is performed for local disease control.
Multidisciplinary input: Melanoma with lymph node involvement (typically positive SLNB) or distant metastasis is discussed in a multidisciplinary setting. Referral to medical oncology for immunotherapy or targeted therapy is coordinated where indicated.
Rare Skin Tumours I also manage less common skin malignancies including:
Dermatofibrosarcoma protuberans (DFSP): A locally aggressive soft tissue sarcoma requiring wide excision with margins of at least 2 cm. The incision orientation is planned from the outset with oncological intent - should re-excision or radiotherapy be required subsequently, the initial approach should not compromise future options.
Merkel cell carcinoma: A rare but aggressive neuroendocrine skin tumour requiring wide excision, SLNB, and multidisciplinary management including consideration of adjuvant radiotherapy.
Marjolin's ulcer: Malignant transformation, most commonly squamous cell carcinoma, arising within a chronic wound (e.g. hidradenitis suppurativa), burn scar, or longstanding pressure sore. Managed with wide local excision and reconstruction, with staging where indicated.
Radiation-induced sarcoma: A rare late complication of radiotherapy, typically presenting a decade or more after treatment as a soft tissue mass or unexpectedly deteriorating wound within a previously irradiated field. Requires biopsy, cross-sectional imaging, and wide excision with reconstruction using well-vascularised tissue from outside the radiation field.
Recovery & Expectations
Recovery depends on the extent of surgery. Simple excision and closure heals within one to two weeks, with most patients returning to normal activities quickly. More complex reconstruction, involving a skin flap or graft, takes longer, with wound healing over three to four weeks and full scar maturation up to twelve months. Sentinel lymph node biopsy adds a separate healing period of two to three weeks at the nodal basin site.
Structured follow-up is arranged according to tumour type and stage. For melanoma, this follows the UK melanoma follow-up schedule with more frequent reviews in the first two years, tapering over five years. For BCC and SCC, follow-up is tailored to the risk profile of the individual tumour. Where referral to medical oncology for systemic therapy is indicated, this is coordinated as part of the overall management plan. I remain involved in the surgical aspects of care throughout, including management of any wound or reconstructive issues that arise during systemic treatment.
Post-operative care extends beyond routine reviews - it is an integral part of Dr Ng’s surgical philosophy. Through Doctor Stitch, an aftercare service founded to ensure seamless continuity and comfort, every patient is followed up personally by Dr Ng for attentive, discreet, and consistent care throughout the recovery journey.
Frequently Asked Questions
1. Do I need a referral to see you for skin cancer?
No referral is required. You can contact me directly via WhatsApp. Sending a photograph of the lesion in advance allows me to give a preliminary view on urgency before your appointment.
2. What is the difference between Doctor Stitch and ZNG Plastic Surgery for skin cancer?
Doctor Stitch handles initial assessment and straightforward excision of low-risk lesions under local anaesthesia in a same-day setting. ZNG Plastic Surgery manages cases requiring wide local excision with flap reconstruction, sentinel lymph node biopsy, lymph node dissection, or multidisciplinary input. The same surgeon manages both, so there is full continuity of care regardless of where treatment begins.
3. What is sentinel lymph node biopsy and do I need it?
Sentinel lymph node biopsy is a staging procedure used primarily for melanoma and selected high-risk SCC. It identifies whether cancer cells have spread to the first draining lymph node. It is not required for all skin cancers. The decision is based on tumour type, thickness, and other pathological features, and is discussed clearly at consultation as it is not without its own risks.
4. I had skin cancer treated overseas. Can you provide follow-up care in Singapore?
Yes. I regularly see patients who had skin cancer managed in Australia, the UK, or elsewhere and require ongoing surveillance in Singapore. I am familiar with the follow-up protocols used in these countries and can continue care within the same framework.
5. Is skin cancer surgery covered by insurance?
Yes. Skin cancer surgery is a medical indication and is generally claimable under medical insurance policies and Medisave for surgical procedures. I can provide documentation to support your claim.
6. How do I know if my lesion needs to be seen urgently?
Features that warrant prompt assessment include a lesion that is growing rapidly, bleeding spontaneously, ulcerating, or changing significantly in a short period. If you are unsure, send a photograph via WhatsApp and I will advise on urgency before your appointment.
Related Reading
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Same-day skin cancer assessment and simple excision via Doctor Stitch
