ECONOMIC EVIDENCE Verdye™ (Indocyanine Green, ICG) in Reconstructive Surgery
THE EVIDENCE
Verdye™ (Indocyanine Green, ICG) enables real-time visualisation of tissue perfusion and vascular flow, helping surgical teams identify poorly perfused tissue during reconstructive surgery.
60%
Lower odds of reoperation in breast reconstruction1
69%
Lower odds of fat necrosis in breast reconstruction1
53%
Lower odds of total flap loss in head and neck reconstruction1
100%
Accuracy assessing burn depth in one prospective study7
THE CHALLENGE
A real-time picture of tissue viability
Adequate tissue perfusion is central to successful reconstructive surgery. When vascular compromise is missed, the consequences can include tissue necrosis, wound breakdown, infection, partial or total flap loss and the need for further intervention. ICG fluorescence angiography provides an additional, real-time assessment of perfusion that complements clinical judgement before, during and after reconstruction.1-4
More than a million reconstructive procedures are performed each year in the US alone, with breast reconstruction representing a substantial proportion of this activity. As procedure volume grows, so does the clinical and economic case for identifying compromised perfusion before wound closure.⁵
Learn more about VerdyeAcross 25 studies including 4,011 patients undergoing breast and head and neck reconstruction patients, intraoperative ICG fluorescence angiography was associated with significantly lower odds of mastectomy skin-flap necrosis, fat necrosis and reoperation in breast reconstruction and lower odds of total flap loss in head and neck construction. Seven included studies also reported cost savings.¹
CLINICAL SETTINGS
Why perfusion assessment matters economically
Reconstructive complications extend well beyond the initial operation. Tissue necrosis, partial or total flap loss and wound breakdown may require debridement, repeat surgery, prolonged hospitalisation, additional dressings and outpatient care. In breast reconstruction, complications can also lead to implant loss, delayed recovery and disruption to subsequent cancer treatment.6-9
ICG fluorescence angiography provides additional perfusion information while the patient is still in theatre.
Poorly perfused tissue can be identified, flap design reconsidered, perforator selection refined or an anastomosis reassessed before the procedure is completed. Its potential economic value therefore comes not from the image alone, but from enabling an earlier change in surgical management that may prevent a costly postoperative complication.1-4
Stat: 11.1% mastectomy skin flap necrosis with ICGFA, versus 16.7% without1
Adequate perfusion of the mastectomy skin flap, nipple–areola complex and autologous flap is fundamental to successful reconstruction. In the 2024 meta-analysis, ICG fluorescence angiography was associated with lower odds of mastectomy skin-flap necrosis (OR 0.58), fat necrosis (OR 0.31) and reoperation (OR 0.40).¹
A 2026 meta-analysis of 100 studies covering 9,704 DIEP flaps found that intraoperative ICG angiography was associated with a 36% reduction in fat-necrosis risk. In a separate 208-patient breast reconstruction study, skin-flap necrosis was 11.5% with ICG angiography compared with 30.8% without it.10,11
Stat: 3.56% total flap loss with ICGFA, vs 7.18% without 1
Free-flap failure in head and neck reconstruction can lead to urgent re-exploration, prolonged hospitalisation and repeat reconstruction. Across four studies involving 701 patients, ICG fluorescence angiography was associated with significantly lower odds of total flap loss (OR 0.47). The analysis did not demonstrate a significant reduction in partial flap loss or reoperation, underlining the need for further prospective evidence.¹
Stat: 28–79% of trauma cases where ICG changed the intraoperative plan 12
In complex extremity trauma, ICG fluorescence imaging can help distinguish perfused from non-viable tissue, define resection margins and assess flap perfusion. Across the published trauma literature, its use changed the intraoperative plan in 28–79% of reported cases, although the evidence is based mainly on small observational series.¹²
In one prospective study of 30 indeterminate burn sites, ICG angiography achieved 100% diagnostic accuracy against histopathology, compared with 50% for clinical assessment alone. This promising finding requires confirmation in larger cohorts.¹³
SURGEON PERSPECTIVE
Why surgeons choose ICG
- Clinical judgement, backed by a real-time picture
- Provides real-time assessment of tissue perfusion1-4
- Helps identify hypoperfused tissue before wound closure¹,³
- Supports flap design, trimming and inset²,³
- Assists perforator selection and evaluation of vascular territories²,¹⁴
- Allows reassessment following microvascular anastomosis²,³
- Can be repeated during a procedure when clinically appropriate³
- Complements clinical assessment when tissue viability is uncertain¹,³
- May prompt immediate revision of the operative plan, potentially avoiding downstream complications¹,¹²
THE ECONOMIC EVIDENCE
Earlier decisions can avoid costly downstream care
The economic burden of reconstructive complications includes much more than the cost of a repeat operation. Flap compromise or tissue necrosis can result in re-exploration, debridement, implant or flap loss, prolonged hospitalisation, additional wound care and delayed recovery.6-9
| Published economic finding | Reported impact | |
|---|---|---|
 |
Retrospective free-flap study | Mean saving of approximately US$972 per patient with ICG angiography⁶ |
|
Australian breast reconstruction analysis | Average cost of treating an ischaemic complication: AU$21,375⁷ |
|
Immediate breast reconstruction study | Skin-flap necrosis reduced from 12.4% to 6.3%, generating net savings of US$185,753 across 206 reconstructions⁸ |
|
2026 systematic economic review | Breast reconstruction studies ranged from a mean US$3 additional cost to US$1,160 saving per patient; average saving approximately US$553⁹ |
|
Cost-utility model in free autologous breast reconstruction | ICGFA produced an incremental cost-utility ratio of approximately US$3,516 per QALY and remained cost-effective when the complication rate without ICGFA was 4% or higher.¹⁵ |
The magnitude of saving will depend on local complication rates, procedure volumes, imaging-system costs and the cost of treating flap-related complications.7-9 Earlier cost modelling suggests that ICG fluorescence angiography may be particularly cost-effective in higher-risk prosthesis-based breast reconstruction patients, including smokers, patients with obesity and those with larger breasts. 1,6
MEASURED PARAMETERS
Evidence that is growing – and becoming more precise
The clinical evidence is strongest in breast reconstruction, with consistent reductions across several perfusion-related outcomes. Evidence in head and neck reconstruction supports a reduction in total flap loss, while trauma and burn applications remain promising but are based on smaller datasets.1,12,13
Current evidence supports ICG fluorescence angiography as a valuable adjunct to clinical judgement, providing additional information when surgeons can still act on it.1,3,4
60% ↓
Lower odds of reoperation in breast reconstruction. 1
42% ↓
Lower odds of mastectomy skin-flap necrosis. 1
Cost comparison
Cost of surgical complications
Complete flap failure adds roughly $11k in inpatient costs per patient. 6
Potential savings with ICG
The same study calculated a mean saving of approx. US$972 per patient with ICG angiography. 6
Fewer complications.Fewer reoperations.
REFERENCES
1. Shapera E, et al. Indocyanine green fluorescence-guided perfusion vs standard assessment to prevent clinical anastomotic leak after colorectal resection: a GRADE-assessed systematic review and meta-analysis of randomised controlled trials. World Journal of Surgical Oncology. 2025;23. doi:10.1186/s12957-025-04163-9.
2. Ontario Health. Indocyanine Green Fluorescence Imaging for Colorectal Surgery: A Health Technology Assessment. Ontario Health Technology Assessment Series. 2025. The primary economic evaluation reported 0.07 additional QALYs and costs lower by C$1,424.
3. Singaravelu A, et al. Clinical and cost-effectiveness of intraoperative flap perfusion assessment with indocyanine green fluorescence angiography in breast and head and neck reconstructions: a systematic review and meta-analysis. Microsurgery. 2024. doi:10.1002/micr.31250.
4. Reeves JJ, et al. The price is right: routine fluorescent cholangiography during laparoscopic cholecystectomy. Surgery. 2022;171(5):1168–1176. PMID:34952715.
5. Hammond J, Lim S, Wan Y, Gao X, Patkar A. The burden of gastrointestinal anastomotic leaks: an evaluation of clinical and economic outcomes. Journal of Gastrointestinal Surgery.
2014;18:1176–1185. doi:10.1007/s11605-014-2506-4.
6. Johnston SS, et al. Impact of indocyanine green fluorescence angiography on surgeon action and anastomotic leak in colorectal resections: a systematic review and meta-analysis. Surgical Endoscopy. 2025. doi:10.1007/s00464-025-11582-y.
7. Liu J, et al. Cost analysis of indocyanine green fluorescence angiography for prevention of anastomotic leakage in colorectal surgery. Surgical Endoscopy. 2022. PMID:35290507.
8. Duggal CS, Madni T, Losken A. An outcome analysis of intraoperative angiography for
postmastectomy breast reconstruction. Aesthetic Surgery Journal. 2014;34(1):61–65.
9. Kanuri A, Liu AS, Guo L. Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction. Plastic and Reconstructive Surgery. 2014. PMID:24675199.
10. Andersson R, Eriksson K, Blind PJ, Tingstedt B. Iatrogenic bile duct injury-a cost analysis. HPB. 2008;10(6):416–419. doi:10.1080/13651820802140745.
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