Indocyanine green applications in plastic surgery: A review of the literature

J Plast Reconstr Aesthet Surg. 2017 Jun;70(6):814-827. doi: 10.1016/j.bjps.2017.01.020. Epub 2017 Feb 20.


Introduction: Use of indocyanine green (ICG) near-infrared fluorescence as a dye to assess tissue vascularization is now well standardized. The aim of this literature review was to review and resume the most recent recommendations for ICG use in its plastic surgery applications.

Methods: A systematic literature review was performed using Medline, EMBASE, and PubMed databases to obtain the latest recommendations for ICG in plastic surgery. Inclusion criteria were all articles written in English language that evaluated pre-, intra-, or postoperative ICG applications in surgical procedures usually performed by plastic surgeons. Case reports, reviews, meta-analyses, and experimental studies on animals or cadavers were excluded after title and abstract screening.

Results: Of the 1389 article titles retrieved, 41 full-text articles met the inclusion criteria. ICG applications in plastic surgery were ICG lymphangiography used in sentinel lymph node mapping for breast cancer and melanoma and in microsurgery for the staging and treatment of secondary chronic lymphedema. The latest updates of ICG angiography in assessing free flaps, pedicled flaps, or large skin paddles were also retrieved.

Conclusions: Large prospective studies suggest that ICG lymphography could be used as a single tracer to reliably perform sentinel lymph node biopsy. In the case of cutaneous melanoma, ICG lymphography increases node detection sensitivity and accuracy in conjunction with lymphoscintigraphy. In chronic lymphedema, it is useful for pre- and postoperative staging and intraoperative anatomical location of lymphatic pathways when lymphovenous bypass is indicated. ICG angiography is used intraoperatively to assess free flap anastomosis and design skin paddles and postoperatively to monitor buried flaps. In pedicled perforator flaps or for large skin paddles, intraoperative ICG angiography is strongly correlated with postoperative outcomes.

Level of evidence: 3.

Keywords: Breast surgery; Chronic lymphedema; Free flaps; Indocyanine green; Microsurgery; Plastic surgery.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Breast Neoplasms / diagnostic imaging
  • Breast Neoplasms / pathology
  • Breast Neoplasms / surgery
  • Chronic Disease
  • Coloring Agents*
  • Female
  • Fluorescein Angiography
  • Humans
  • Indocyanine Green*
  • Lymphedema / diagnostic imaging
  • Lymphedema / surgery
  • Lymphography / methods
  • Melanoma / diagnostic imaging
  • Melanoma / pathology
  • Melanoma / surgery
  • Microsurgery / methods
  • Reconstructive Surgical Procedures / methods*
  • Sentinel Lymph Node Biopsy / methods
  • Skin Neoplasms / diagnostic imaging
  • Skin Neoplasms / pathology
  • Skin Neoplasms / surgery
  • Surgical Flaps / blood supply


  • Coloring Agents
  • Indocyanine Green

Supplementary concepts

  • Melanoma, Cutaneous Malignant