Indocyanine green angiography in breast reconstruction: Utility, limitations, and search for standardization

Background: During reconstructive breast surgery, intraoperative assessment of tissue perfusion has been solely based on subjective clinical judgment. However, in the last decade, intraoperative indocyanine green angiography (ICGA) has become an influential tool to visualize blood flow to the tissue of interest. This angiography technique produces real-Time blood flow information to provide an objective assessment of tissue perfusion. Methods: A comprehensive literature search of articles pertaining to ICGA in breast reconstruction surgery was performed. The overall findings of the articles are outlined here by surgical procedure: skin-sparing and nipple-sparing mastectomy, implant-based reconstruction, and autologous reconstruction. Results: Overall, there were 133 articles reviewed, describing the use of ICGA in breast reconstruction surgery. We found that ICGA can provide valuable information that aids in flap design, anastomotic success, and perfusion assessment. We also included example photographs and videos of ICGA use at our institution. Conclusions: ICGA can reduce postoperative tissue loss and aid in intraoperative flap design and inset. Despite the benefits of ICGA, its technical use and interpretation have yet to be standardized, limiting its widespread acceptance.