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Background Skin flap necrosis is a common complication after mastectomy, and indocyanine green (ICG) has been used successfully to visualization for intraoperative evaluation. The effect of ICG on postoperative skin flap necrosis after mastectomy remains controversial. We conducted a systematic review and meta-analysis to explore the prevention of ICG versus no ICG on postoperative flap necrosis. Methods We searched PubMed, Embase, and Cochrane library from Jan 1900 to Nov 2022 for retrospective cohort studies (RCSs) to assess the effect of ICG versus no ICG on postoperative skin flap necrosis. This meta-analysis system review was performed by the PRISMA guideline. Results Our meta-analysis identified six RCSs, including 858 patients after mastectomy and breast flap reconstructive. Compared with the control group for mastectomy, we found that ICG may significantly reduce skin flap necrosis (OR = 0.64; 95% CI 0.44 to 0.94; I2 = 51%; P = 0.02), severe flap necrosis (OR = 0.27; 95% CI 0.12 to 0.58; I2 = 0%; P = 0.0008), reoperation rates (OR = 0.37; 95% CI 0.22 to 0.64; I2 = 10%; P = 0.0003). ICG had no difference in infection (OR = 0.91; 95% CI 0.53 to 1.55; I2 = 0%; P = 0.72) and seroma (OR = 1.37; 95% CI 0.76 to 2.49; I2 = 0%; P = 0.30). Conclusions We found that the incidence of breast skin flap necrosis was statistically lower in the ICG group than that in the control group. ICG is effective to prevent the flap necrosis risk after breast surgery.

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