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Indocyanine Green Angiography Reduces Ischemic Complications in Immediate Implant-Based Breast Reconstruction: A
Seung-Ho Choi1, Sang-Oh Lee1, Du-Hyong Cho2
1Department of Plastic and Reconstructive Surgery, Yeungnam University College of Medicine, Daegu, 42415, Republic of Korea.
Background:
Skin- and nipple-sparing mastectomy followed by immediate implant-based breast reconstruction (IBBR) has grown substantially in clinical practice, yet mastectomy skin flap necrosis (MSFN) persists as a clinically significant source of morbidity. Intraoperative indocyanine green angiography (ICGA) enables real-time, objective quantification of skin flap perfusion, but its specific effect on IBBR outcomes has yet to be established through dedicated meta-analytic synthesis. This study aimed to evaluate whether intraoperative ICGA-guided decision-making lowers the incidence of MSFN and related surgical complications relative to conventional clinical appraisal in immediate IBBR.
Methods:
Four databases-PubMed, Embase, Scopus, and the Cochrane Library-were searched through March 2026 for comparative studies of immediate IBBR. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel method.
Results:
Nine studies comprising 1,356 reconstructed breasts (655 ICGA; 701 clinical assessment) met inclusion criteria. ICGA was associated with significantly lower risks of overall MSFN (RR 0.57, 95% CI 0.44-0.73) and severe MSFN (RR 0.35, 95% CI 0.22-0.55), as well as reduced return to the operating room, surgical-site infection, and flap salvage procedures. Overall complication rates, hematoma/seroma, and implant loss were not significantly different between groups.
Conclusions:
Intraoperative ICGA significantly reduced the risk of overall MSFN by approximately 43% and severe MSFN by approximately 65%, with fewer unplanned reoperations and flap salvage procedures, without affecting non-ischemic outcomes. The evidence supports selective incorporation of ICGA into IBBR surgical protocols, with particular emphasis on patients carrying elevated perfusion-related risk.
Level Of Evidence Iii:
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .