Near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) was considered to have the potential to improve sentinel lymph node (SLN) mapping in breast cancer. Herein, we performed a randomized clinical trial to evaluate the effectiveness of ICG fluorescence imaging compared with blue dye imaging in SLN navigation surgery. We also analyzed lymph drainage pathways to identify targets for sentinel lymph node biopsy (SLNB). Finally, 68 consecutive patients diagnosed with breast cancer and who underwent SLNB between November 2010 and September 2012 were enrolled in the study. The cases were randomly grouped into either the ICG fluorescence or blue dye group, with 36 in the ICG fluorescence group and 32 in the blue dye group. Levels I and II axillary dissection was performed in all cases after SLNB. A single lymph drainage pathway was detected in 21 of 36 (58.3%) patients, and multiple lymph drainage pathways were detected in 15 of 36 (41.7%) cases. The detection rate of SLNB was higher by ICG fluorescence than by blue dye (97.2 vs. 81.3%, p < 0.05), as 3.6 SLNs were detected on average in the ICG fluorescence group compared to 2.1 in the blue dye group. However, the sensitivity and false-negative rate were similar in the two groups. In conclusion, ICG fluorescence was superior to blue dye for the identification of the SLN.