Background: Axillary lymph node dissection (ALND) in breast cancer patients is infamous for its accompanying morbidity. Selective preservation of upper extremity lymphatic drainage and accompanying lymph nodes crossing the axillary basin - currently resected during a standard ALND - has been proposed as a valuable surgical refinement. Methods: Peroperative Axillary Reversed Mapping (ARM) was used for selective preservation of upper extremity lymphatic drainage. A multicentre patient- and assessor-blinded randomised study was performed in clinical node negative, sentinel node positive early breast cancer patients. Patients were randomized to undergo either standard-ALND or ARM-ALND. Primary outcome was the presence of surgery-related lymphedema at six, 12 and 24 months post-operatively, measured by the water displacement method. Secondary outcomes included patient reported and objective signs and symptoms of lymphedema, pain, paraesthesia, numbness, loss of shoulder mobility, quality of life and axillary recurrence risk. Results: No significant differences were found between both groups using the water displacement method with respect to measured lymphedema. ARM-ALND resulted in less reported complaints of lymphedema at six, 12 and 24 months postoperatively (p<0.05). Postoperative numerical differences of arm/shoulder pain, necessity to wear a compressive arm sleeve favouring ARM-ALND were only significant at six months (p=0.039 and p=0.043 respectively) as compared to 24 months (p=0.076 and p=0.066). No axillary recurrence was found in both groups. Interpretation: In contrast to results of volumetric measurement, patient reported outcomes support selective sparing of the upper extremity lymphatic drainage using ARM as valuable surgical refinement in case of ALND in clinically node negative, sentinel node positive early breast cancer. If completion ALND in clinically node negative, sentinel node positive early breast cancer is considered, selective sparing of upper extremity axillary lymphatics by implementing ARM should be carried out in order to reduce morbidity. Trial Registration Number: The trial is registered in the Dutch trial registration (TC 3698). Funding Statement: Pink Ribbon foundation (currently KWF) and the Maurits and Anna the Kock foundation Declaration of Interests: The authors have no financial of non-financial competing interest to declare. Ethics Approval Statement: Ethical approval for this study was provided by the medical ethics committee (METC) of Maxima Medisch Centrum, Veldhoven, The Netherlands. Informed consent was obtained from each participant prior to the operation. This study was carried out in compliance with the Helsinki Declaration.