Two of the greatest challenges in breast reconstruction are mastectomy skin flap necrosis (MSFN) and autologous flap failure. This review summarizes current evidence regarding the usage of indocyanine green angiography (ICGA) in breast reconstruction, identifies knowledge gaps, and provides directions for future studies. An umbrella review was conducted to identify related syntheses in Embase, Ovid Medline, Scopus, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and the Clinical Trials databases. Data were extracted from systematic reviews (SRs) and meta-analyses (MAs) that discussed the use of ICGA in breast reconstruction. Sixteen syntheses were included (10 SRs and 6 MAs). Syntheses showed much evidence that ICGA usage typically reduces MSFN rates. However, it tends to overpredict necrosis and is best utilized in high-risk patients or those with an unclear clinical picture. ICGA is also useful in autologous breast reconstruction by reducing rates of breast fat necrosis (BFN), total flap loss, and reoperation. ICGA usage may also aid in perforator mapping and selection intraoperatively, with minimal complication risk. Most syntheses had moderate quality scores; however, they were small with significant heterogeneity in protocols and complication definitions. The use of ICGA in breast reconstruction is safe and useful in decreasing rates of MSFN, BFN, and reoperation after free flap reconstruction.
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