The role of indocyanine green fluorescence angiography in head and neck reconstruction: a systematic review

This systematic review examined the use of Indocyanine Green Fluorescence Angiography (ICG-FA) to evaluate flap viability in reconstructive head and neck surgery. PUBMED, Embase, and Cochrane Library were systematically reviewed. Key outcomes assessed were feasibility of intraoperative ICG-FA, intraoperative alterations, postoperative monitoring, and the predictive value of ICG-FA for flap viability. Fourteen observational cohort studies were included (total n = 1826). ICG-FA was integrated into surgical workflows with minimal disruptions. It helped guide intraoperative alterations and decisions, such as flap design and re-anastomosis. For postoperative monitoring, ICG-FA supported early detection of perfusion deficits, enabling timely interventions. Quantitative perfusion thresholds for impaired viability were mostly relative, ranging from 20% to 50% fluorescence reduction compared to reference areas, derived either retrospectively or based on predefined cutoffs. ICG-FA appears to be a feasible tool for real-time perfusion assessment in head and neck reconstruction. However, the evidence its clinical applicability remains limited by methodological heterogeneity and a serious risk of bias in a proportion of the included studies. Standardization of protocols and prospective validation are needed to enhance clinical application.