Purpose of Review <p>Surgical management of the axilla has significantly evolved over the past several decades. Spurred by growing evidence, de-escalation of nodal surgery and incorporation of radiation minimizes treatment-related morbidity while maintaining oncologic outcomes. This review outlines the historical and contemporary literature forming the evidence base for current treatment guidelines.</p> Recent Findings <p>Nodal status remains a key prognostic factor in breast cancer. Historically, axillary lymph node dissection was critical to defining pathologic nodal stage. However, several landmark clinical trials have established sentinel node dissection as the optimal approach for nodal staging in patients with clinically-node negative disease. Furthermore, incorporation of neoadjuvant therapy facilitates limited axillary surgery in selected patients thereby further personalizing therapy and minimizing morbidity. Regional nodal radiation is recommended in high-risk patients.</p> Summary <p>De-escalation of nodal surgery coupled with the expansion of neoadjuvant systemic therapy and adjuvant radiation has accelerated significant advancement in breast cancer care.</p>