Background Targeted Axillary Dissection (TAD) is now commonly used in breast cancer patients undergoing neoadjuvant therapy (NACT) to minimize the morbidity associated with axillary lymph node dissection. This study explores four years of experience with TAD at Chris O’Brien Lifehouse, focusing on its outcomes and implementation. Methods We analyzed data from 62 patients treated with TAD between 2020 and 2023. The study included patient demographics, tumor and nodal characteristics, surgical approaches, and treatment outcomes. Results The median age of patients was 47 years (IQR 41–57), with 53.2% being premenopausal. Luminal B was the most common tumor subtype (29%), followed by HER2-only (27%), triple-negative (26%), and triple-positive (18%). The mean tumor size was 35.1mm, with 62.9% of tumors measuring 21–50mm. Node involvement was seen in 96.8% of cases, with a median of 1.78 nodes identified. Clipped nodes were successfully removed in 95.2% of patients, with scout localization achieving 100% accuracy compared to 87% with other methods. Pathologic complete response (pCR) was achieved in 46.7% of patients, highest in HER2-only cases (35.3%). For patients with residual disease, the mean tumor size was 23.4mm. Over the years, fewer nodes were dissected during TAD, reflecting improved localization techniques. Postoperative complications were rare, with only 12.9% requiring seroma aspiration. Conclusion Our findings highlight TAD as a safe and effective approach for axillary management in breast cancer, offering precise node localization and reduced surgical morbidity. With ongoing refinement, TAD continues to enhance outcomes and surgical planning.