Axillary surgery has undergone major changes over the last 20+ years, from routine axillary lymph node dissection (ALND) to the use of sentinel lymph node (SLN) surgery and even omission of axillary surgery in select patients with breast cancer. SLN surgery was initially developed in the setting of upfront surgery in patients with clinically node-negative presentation, but subsequently expanded to be used following neoadjuvant chemotherapy (NAC). ALND was then shown to be safely omitted with 1–2 positive sentinel lymph nodes in the upfront setting. Most recently, axillary surgical staging is being increasingly omitted altogether in patients with small favourable breast cancer (cT1 HR+/Her2− disease with negative axillary ultrasound). In the setting of NAC, there has also been a major shift from ALND to SLN surgery both in patients with clinically node-negative disease at presentation, as well as those with clinically node-positive disease at presentation who convert to clinically node-negative after NAC. There has been wide variation in trial result incorporation into clinical practice, with some surgeons slowly adopting practice changes and others extrapolating trials to other clinical scenarios prior to publication of trials in that setting. Data is eagerly awaited regarding oncologic safety of omission of ALND in the setting of ypN+ disease after NAC. Ultimately, axillary surgery is adjusting to ensure the appropriate information is obtained to guide adjuvant therapies, while minimizing the number of patients undergoing ALND and therefore being put at risk of the morbidity associated with ALND.