Background: The evaluation of axillary lymph nodes (ALNs) using ultrasound (US) is an important part of the diagnosis and treatment in patients with breast cancerThe aim of this study is to assess the diagnostic effectiveness of superb microvascular imaging (SMI) in suspicious axillary lymph nodes. To the best of our knowledge, our study is the first in the literature to evaluate the highest number of suspicious axillary lymph nodes using SMI and to assess the combined contribution of quantitative and qualitative data to the diagnosis.Patients and Methods: Our prospective study involved 102 patients with suspicious lymph nodes in the axilla. SMI method was employed individually to assess distribution, appearance, and number of vascular structures. After histopathological or follow-up confimation, images were re-evaluated. We also examined the diagnostic value of various combinations of these vascular features. Lastly, two radiologists, each with 22 and 4 years of experience, independently reviewed the images, blinded to clinical and pathological data, to assess interobserver agreement.Results: A total of 108 lymph nodes were evaluated in 102 patients, including 67 benign and 41 malignant cases. The diagnostic performance of various combinations in receiver operating characteristic (ROC) analysis revealed that the highest accuracy (78.70%) and area under the curve (AUC) value in ROC analysis were achieved by distribution-appearance combinations (AUC: 0.776, p<0.001). Interobserver agreement was significant for both the SMI and PDUS methods.Conclusion: In conclusion, our findings suggest that SMI facilitates more accurate identification of suspicious axillary lymph nodes prior to surgical intervention.