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. 2025 Jul 22;25(1):311.
doi: 10.1186/s12893-025-03048-8.

The impact of indocyanine green fluorescence imaging on skin flap necrosis: a systematic review and meta-analysis

Lin Chun #  1 , Zhiping Fu #  1 , YingJun Zheng  2 , Haomin Lin  3 , Yue Hu  4   5 , Donglun Li  6
Affiliations

The impact of indocyanine green fluorescence imaging on skin flap necrosis: a systematic review and meta-analysis

Lin Chun et al. BMC Surg. .

Abstract

Background: Skin flap necrosis is a prevalent complication following mastectomy, significantly impacting patient recovery. Indocyanine green (ICG) fluorescence imaging offers intraoperative guidance by providing real-time evaluation of tissue perfusion; however, its efficacy in reducing postoperative necrosis remains a subject of debate. This study seeks to elucidate the impact of ICG on postoperative skin flap necrosis and the rate of reoperation through a systematic review and meta-analysis.

Methods: We systematically searched the PubMed, Embase, and Cochrane Library databases, incorporating seven retrospective cohort studies and one prospective study into our analysis. Data analysis was performed using Review Manager 5.4, this systematic review and meta-analysis was reported in accordance with the PRISMA guidelines.

Results: Our analysis included eight articles with a total of 1,252 patients who underwent mastectomy and breast flap reconstructive surgery. Our findings indicate that, compared with the control treatment, the use of indocyanine green (ICG) can significantly reduce the occurrence of skin flap necrosis (OR = 0.60; 95% CI 0.44 to 0.81; I2 = 0%; P = 0.001), severe flap necrosis (OR = 0.37; 95% CI 0.22 to 0.63; I2 = 0%; P = 0.0002), and reoperation (OR = 0.49; 95% CI 0.33 to 0.73; I2 = 28%; P = 0.0005).

Conclusions: The findings suggest that ICG can effectively reduce the risk of severe skin flap necrosis and the necessity for reoperation post-mastectomy, although its benefits for mild to moderate necrosis are limited. Future research should focus on multicenter randomized controlled trials to standardize the application of ICG and assess its feasibility in resource-constrained settings.

Keywords: Breast reconstruction; Flap necrosis; Indocyanine green; Mastectomy; Reoperation.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Not applicable. This article does not contain any studies with human participants or animals performed by any of the authors. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Flow diagram of study selection
Fig. 2
Fig. 2
Cochrane risk of bias assessment graph
Fig. 3
Fig. 3
Forest plot of the necrosis rate after mastectomy alone and after breast reconstruction
Fig. 4
Fig. 4
Forest plot for mild, moderate, and severe flap necrosis
Fig. 5
Fig. 5
Forest plot of reoperation
Fig. 6
Fig. 6
Forest plot of infection
Fig. 7
Fig. 7
Forest plot of seroma
Fig. 8
Fig. 8
Forest plot of imaging devices
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