BACKGROUND: Breast cancer-related lymphedema (BCRL) significantly affects quality-of-life after axillary lymph node dissection (ALND). Although immediate lymphatic reconstruction (ILR) may reduce BCRL incidence, its long-term outcomes and predictors remain unclear. We report long-term BCRL prevalence in patients undergoing ILR and delineate factors associated with BCRL after ILR. METHODS: We retrospectively studied consecutive patients who underwent ILR following ALND between 2017 and 2024 across six hospitals in the Indiana University network. Primary outcome was BCRL prevalence, defined as ≥ 2-cm limb difference at two contiguous points. Secondary outcomes included BCRL predictors, postoperative complications, and compression garment use. RESULTS: We identified 172 patients with a mean age 50.9 ± 11.6 years, body mass index of 29.5 ± 6.9 kg/m, and follow-up time of 23.1 ± 15.2 months. Most patients (57.7%) underwent mastectomy, ALND with breast reconstruction. The median number of lymph nodes removed during ALND was 15 (interquartile range [IQR] 10.0-21.0), and median number of positive lymph nodes was 2.0 (IQR, 0.0-4.0). The cumulative BCRL incidence was 7.0% (n = 12 patients). Median time to significant limb swelling was 4.5 (IQR, 1.0-11.3) months. Fifty-five patients (32.0%) used postoperative compression garments. Breast-related complications occurred in 30.2% of patients. Black/African American patients had significantly higher lymphedema rates than White patients (18.8% vs. 4.5%, p = 0.005). In adjusted analyses, Black/African American race was an independent predictor (odds ratio [OR], 6.38; p < 0.006) of BCRL. CONCLUSIONS: Immediate lymphatic reconstruction following ALND demonstrated low BCRL rates, although Black or African American patients remain at disproportionately higher risk, warranting targeted interventions and further investigation.