Indocyanine Green Angiography Reduces Ischemic Complications in Immediate Implant-Based Breast Reconstruction: A Systematic Review and Meta-analysis

Why clinicians should know about it

• Picked for Plastic and Reconstructive Surgery (paper of the day, 17 October 2026): ICG angiography reduces ischemic complications in implant‑based reconstruction

Abstract

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 .

Abstract as published, via PubMed.