Role of Indocyanine Green Angiography in Free Flap Surgery: A Comparative Outcome Analysis of a Single-Center Large Series of 877 Consecutive Free Flaps.

 This study aims to assess and validate the role and cost-effectiveness of indocyanine green angiography (ICGA) in free flap surgery outcomes. A new intraoperative protocol of whole-body surface warming (WBSW) for all free flap surgeries during the strategic "microbreaks" is also described.  A retrospective analysis of 877 consecutive free flaps, performed over 12 years, is presented. The results of the ICGA group (  = 438) were compared with the historical No-ICGA group (  = 439), and statistical significance was calculated for three crucial flap-related adverse outcomes and cost-effectiveness. ICGA was also used as a tool to show the effect of WBSW on free flaps.  ICGA showed a notably strong statistical significance in decreasing two outcome parameters, namely, partial flap loss and re-exploration rate. It was also cost-effective. ICGA also demonstrated the positive role of WBSW in increasing flap perfusion.  Our study shows that the usage of ICGA for intraoperative assessment of flap perfusion can significantly reduce the partial flap loss and re-exploration rate in free flap surgeries in a cost-effective manner. A new protocol of WBSW is also described and recommended to increase flap perfusion in all free flap surgeries.