• flap perfusion
• ICG angiography
• plastic surgery
• postoperative complications

Indocyanine green (ICG) angiography is a valuable imaging technique that utilizes a fluorescent contrast agent, indocyanine green dye, which is injected either intravenously or subcutaneously. When illuminated by near-infrared light, the dye fluoresces, enabling real-time visualization of blood and lymphatic vessels. This allows surgeons to assess tissue perfusion dynamically during surgical procedures. Due to its relatively low risk profile and broad applicability, ICG angiography has gained widespread use across multiple medical specialties, including cardiology, oncology, and plastic surgery. In the field of plastic surgery, ICG angiography is especially important for evaluating lymphedema and assessing flap perfusion intraoperatively, which is the primary focus of this study.
Flap perfusion is a critical determinant of surgical success in reconstructive procedures. Insufficient blood supply to the transplanted tissue, or flap, can lead to a range of postoperative complications, including seroma formation, wound dehiscence, infection, and tissue necrosis. These complications not only prolong hospital stay and increase healthcare costs but may also necessitate further surgical interventions. By enabling the surgeon to visualize blood flow within the flap in real-time, ICG angiography facilitates immediate assessment and decision-making. This technique allows for timely identification of poorly perfused tissue segments, enabling adjustments in flap design.
This study involved 24 patients who underwent reconstructive surgery with either pedicled or free flaps. All patients were intraoperatively evaluated using ICG angiography to assess the perfusion status of the harvested flaps. Subsequent follow-up was conducted to monitor for postoperative complications. Statistical analysis was performed using Fisher’s exact test to determine the association between the intraoperative ICG-assessed perfusion and the incidence of complications, with significance set at a p-value less than 0.05.
Consistent with previous findings in the literature, the statistical analysis revealed a significant correlation (p = 0.0217) between poor perfusion detected with ICG angiography and the occurrence of postoperative complications. These results support the clinical utility of intraoperative ICG angiography as a tool to optimize flap preparation and to promptly address any perfusion deficits during surgery, potentially reducing the risk of adverse outcomes.
Moreover, the study discusses four clinical cases involving different flap types: the anterolateral thigh (ALT) flap, the reverse radial forearm (RRF) flap, the nasolabial flap, the posterior tibial artery perforator (PTAP) flap and the deep inferior epigastric perforator (DIEP) flap . These cases serve as practical examples illustrating the effectiveness of ICG angiography in detecting both adequate and inadequate perfusion. The timely detection of perfusion abnormalities in these varied flap types underscores the versatility and broad applicability of ICG angiography in reconstructive plastic surgery.
Overall, this study supports the role of ICG angiography as a valuable intraoperative imaging tool. By providing real-time data on flap vascularization, it helps surgeons to preemptively assess perfusion defects and improve flap viability, thus reducing postoperative complications. Future research with larger patient cohorts could further validate these findings and contribute to the development of standardized protocols incorporating ICG angiography into reconstructive surgery.