Background: Near-infrared fluorescence (NIRF) imaging has gained prominence in plastic and reconstructive surgery because of its ability to visualize tissue perfusion and vascular integrity in real-time. This study aimed to highlight the clinical indications of this technology, review clinical applications of imaging and evaluate impact on surgeon’s decision under various surgical scenarios. Materials and Methods: Patients who had NIRF imaging between 2017 and 2024 were identified through database retrospectively. Patient demographics, the procedure performed, the indication for imaging, and the surgeon’s decision before and after imaging were collected. Descriptive analysis was performed to evaluate the utility of imaging in different surgical scenarios. Results: Data of 26 patients were included in the study. NIRF imaging was found to be highly effective in visualizing vascular structures and assessing tissue viability. Technology appears to be particularly useful for optimizing perforator selection in flaps with multiple perforators and plays a decisive role in clinical decision-making for assessing perfusion in microsurgical tissue reconstruction, identifying sentinel lymph nodes, and managing infections that could compromise tissue viability. Conclusions: NIRF imaging has proven to be a decision-influencing tool for evaluating anastomosis patency and tissue perfusion in microsurgery, as well as for identifying sentinel lymph nodes. However, it has shown limited impact in areas such as wound healing, assessment of infection-related tissue changes, and evaluation of perfusion in aesthetic procedures. Larger controlled studies are needed to further validate its effectiveness and clarify its clinical utility.