Purpose The surgical management of breast cancer has evolved with expectations for improved surgical, functional, aesthetic and oncological outcomes. This study aimed to describe these trends over time in breast cancer management in a large metropolitan centre. Method This retrospective cohort study assessed patients with breast cancer treated by four surgeons at the Westmead Breast Cancer Institute from 1 Jan 2015 to 31 Dec 2024. Data was extracted from surgeons’ logbooks and chart review, for procedures in both public and private hospitals. Linear regression models were used to identify statistical significance of trends over time. Results A total of 5709 patients were included. The rate of breast conserving surgery (BCS) increased progressively from 61% to 79%, while mastectomies decreased from 39% to 21% (p<0.01). Simultaneously, the proportion of neoadjuvant systemic therapy increased from 6% to 27% (p<0.01). The use of localisation for non-palpable disease doubled from 29% to 62% (p<0.01). Oncoplastic breast surgical techniques increased from 37% to 56% of BCS cases, with local perforator flap and immediate lipofilling increasing from 5% in 2018 to 22% in 2024 (p<0.01). The rate of immediate post-mastectomy reconstruction remained stable at around 45%; the proportion of implant-based vs autologous reconstruction changed from 95% vs 5% in 2020 to 51% vs 49% in 2024 (p<0.01). Symmetrisation of the contralateral breast doubled from 11% to 23% (p<0.01). The proportion of axillary lymph node dissection (ALND) decreased from 16% to 6%, whereas targeted axillary dissection (TAD) increased from 0% to 10% (p<0.01). Of patients with upfront TAD, 36% proceeded to cALND. Lymphovascular anastomosis was introduced in 2024. Conclusion Breast surgery has moved away from mastectomies and towards breast conservation, with de-escalation of axillary surgery and improvement in cosmetic outcomes. These changes reflect advances in oncoplastic breast surgery and use of neoadjuvant therapy.