Background <p>Skin flap necrosis is a prevalent complication following mastectomy, significantly impacting patient recovery. Indocyanine green (ICG) fluorescence imaging offers intraoperative guidance by providing real-time evaluation of tissue perfusion; however, its efficacy in reducing postoperative necrosis remains a subject of debate. This study seeks to elucidate the impact of ICG on postoperative skin flap necrosis and the rate of reoperation through a systematic review and meta-analysis.</p> Methods <p>We systematically searched the PubMed, Embase, and Cochrane Library databases, incorporating seven retrospective cohort studies and one prospective study into our analysis. Data analysis was performed using Review Manager 5.4, this systematic review and meta-analysis was reported in accordance with the PRISMA guidelines.</p> Results <p>Our analysis included eight articles with a total of 1,252 patients who underwent mastectomy and breast flap reconstructive surgery. Our findings indicate that, compared with the control treatment, the use of indocyanine green (ICG) can significantly reduce the occurrence of skin flap necrosis (OR = 0.60; 95% CI 0.44 to 0.81; <i>I</i>² = 0%; <i>P</i> = 0.001), severe flap necrosis (OR = 0.37; 95% CI 0.22 to 0.63; <i>I</i>² = 0%; <i>P</i> = 0.0002), and reoperation (OR = 0.49; 95% CI 0.33 to 0.73; <i>I</i>² = 28%; <i>P</i> = 0.0005).</p> Conclusions <p>The findings suggest that ICG can effectively reduce the risk of severe skin flap necrosis and the necessity for reoperation post-mastectomy, although its benefits for mild to moderate necrosis are limited. Future research should focus on multicenter randomized controlled trials to standardize the application of ICG and assess its feasibility in resource-constrained settings.</p>