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Sentinel lymph node dissection (SLND) during mastectomy has been increasing given the decreased risk of lymphedema. Simultaneous reconstruction with a microsurgical breast reconstruction is often performed, but with node positivity a completion axillary lymph node dissection (ALND) must be performed subsequently. This study examines the potential risks especially in relation to microsurgical reconstruction. All patients undergoing microsurgical breast reconstruction at an academic institution from 2004 to 2010 were evaluated in a prospective database. Patients with immediate reconstruction and SLND were identified. Management of positive lymph node status was ascertained through extensive chart review. There were 610 reconstructions performed, 170 delayed and 440 immediate. From the immediate reconstructions, 110 patients (25%) had SLND and of these patients, 16 (14.55%) had a positive SLND. All 16 patients had internal mammary recipient vessels for free tissue transfer. Seven patients had intraoperative completion ALND, while nine patients had staged completion ALND at a later date. There were no adverse affects from completion ALND. Simultaneous mastectomy, SLND, and microsurgical reconstruction can be performed safely. The internal mammary vessels are preferred recipient vessels as node positive patients may require subsequent completion ALND. If a thoracodorsal anastomosis is performed, a potential risk exists for vessel injury and flap loss with completion ALND.