Intraoperative Indocyanine Green Angiography as a Predictor of Complications in Breast Cancer Patients Undergoing Conservative Mastectomy

BACKGROUND: Conserving mastectomy techniques, such as nipple-sparing and skin-sparing mastectomy, enable immediate breast reconstruction, improving aesthetic outcomes but increasing the risk of postoperative complications, particularly ischemic events related to mastectomy skin flap perfusion. Intraoperative assessment with indocyanine green angiography has emerged as a tool to evaluate vascularization in real time. PATIENTS AND METHODS: A single-center retrospective study was conducted on patients undergoing conserving mastectomy with immediate prosthetic reconstruction from 2023 to 2026. Intraoperative flap perfusion was graded using indocyanine green (ICG) angiography. Clinical variables, surgical characteristics, postoperative complications, and time-to-adjuvant therapy were analyzed. Univariate and multivariate analyses were performed to identify predictors of complications. RESULTS: Forty-eight conserving mastectomies were included. Nine patients (18.7%) showed intraoperative hypoperfusion (score < 2). Complication rates were significantly higher in the hypoperfused group (P = .001). Mastectomy flap thickness was lower in hypoperfused flaps (mean difference ≈2 mm; P = .031). Low perfusion was also associated with delayed initiation of adjuvant therapy (36.8 vs. 13.7 days; P = .051). In multivariate analysis, hypoperfusion remained the strongest predictor of complications and longer interval to adjuvant treatment (P = .030 and P < .001). CONCLUSION: ICG angiography documented mastectomy skin flap hypoperfusion is strongly associated with ischemic complications and delayed access to adjuvant treatments. Intraoperative perfusion assessment may guide surgical decision-making and support preventive strategies. Prospective studies are warranted to validate objective perfusion scoring models.