The goals of axillary management in early breast cancer have changed substantially in recent years. Whereas axillary surgery was once viewed primarily as a means of local control, current practice asks whether axillary staging information changes subsequent treatment decisions. With advances in antibody-drug conjugates, novel endocrine therapies, and radiotherapy techniques, selected patients may achieve favorable regional control and quality of life despite less extensive axillary surgery. This review summarizes evidence for three approaches to axillary de-escalation. The first is omission of sentinel lymph node biopsy in carefully selected, low-risk patients with clinically node-negative disease. The second is omission of axillary lymph node dissection or its replacement with axillary radiotherapy in selected patients with positive sentinel nodes. The third is restaging with targeted axillary dissection in initially node-positive patients who become clinically node-negative after neoadjuvant therapy. Axillary de-escalation should be based on reliable imaging, standardized pathologic assessment, and multidisciplinary discussion. Molecular subtypes, including HER-2-positive and triple negative breast cancer, should inform whether less extensive surgery would alter systemic therapy, regional radiotherapy or follow-up.