BACKGROUND The Multicenter Selective Lymphadenectomy Trial II results suggest that future radical axillary lymphadenectomy (ALND) will be performed for bulkier metastatic disease. The utility of level III lymph node (LN) dissection in melanoma patients with palpable metastatic axillary disease was assessed. METHODS We performed a retrospective chart review of patients who underwent ALND (levels I-III) for metastatic melanoma from 2005 to 2017. We assessed the frequency of level III positive nodes in patients undergoing radical axillary lymphadenectomy (ALND) for metastatic melanoma as well as the prognostic role and factors predictive of level III LN positivity. RESULTS A total of 190 patients underwent ALND during the study period. Of these, 85 patients had palpable axillary disease, of which 71 had separate level III pathologic assessment. Level III LNs were positive in 16.9% of patients with palpable disease versus 0% with positive sentinel LN. The 1-, 3-, and 5-year overall survival (OS) for patients with palpable disease was 82.9%, 58.9%, and 39.0%, respectively. Median disease-free survival was 26.8 months, and the axillary recurrence rate was 8.2%. High level I/II LN ratio, BRAF mutation, and total LN examined were significant predictors of level III positivity (all p ≤ 0.05). Patients with positive level III LN had significantly worse OS (median 18.6 months vs. not reached, p = 0.001). No preoperative factors were predictive of level III LN positivity. CONCLUSIONS Level III axillary disease is not uncommon in melanoma patients with clinically palpable nodal disease and provides useful prognostic information for OS. We recommend that full level I-III ALND be considered in this patient cohort.