Background: Efforts to minimize the false negative rate (FNR) of axillary staging in cN1 breast cancer patients (pts) treated with neoadjuvant chemotherapy (NAC) have received much attention since the publication of ACOSOG Z1071. We first adopted sentinel node biopsy (SNB) with a requirement of retrieving ≥3 nodes, and later transitioned to targeted axillary dissection (TAD) with a requirement of retrieving the biopsy-proven clipped node (CN) and ≥3 nodes overall. Group consensus was to perform axillary lymph node dissection (ALND) if these technical requirements were not met. This study evaluates likelihood of surgical overtreatment with ALND due to technical failures of SNB or TAD in cN1 pts who converted to ypN0 status, and reports oncologic outcomes with each approach. Methods: Among 598 cN1 breast cancer pts treated with NAC from 2017-2022 in our prospective institutional database, we included 191 (31.9%) with attempted SNB or TAD and ypN0 status. We used descriptive statistics and chi-squared tests to compare technical complications of SNB vs. TAD resulting in requirement for ALND per group consensus despite ypN0 status. Kaplan Meier methods were used to determine oncologic outcomes in those treated with SNB or TAD alone. Results: Planned axillary surgery was SNB in 77 (40.3%) pts and TAD in 114 (59.7%). The CN was not visualized for seed localization in 14 pts (12.2% of planned TAD) and the seed was not found to be within the CN intra-operatively in 20 pts (20.0% of those with seed placed). Technical failures resulting in requirement of ALND per group consensus criteria occurred in 14 (18.2%) pts with planned SNB and 17 (14.9%) with planned TAD. Among planned TAD pts, the rate of not retrieving the CN did not change over time (p=0.52). Median follow-up in those treated with SNB alone (n=79) was 3.5 years with 1 (1.3%) axillary recurrence as well as 2 local and 2 distant recurrences and 1 non-breast cancer death. 3-yr recurrence-free survival was 90.4% (95%CI: 79.5-95.7%). Median follow-up in those with TAD alone (n=92) was 1.8 years with no recurrences or deaths. Conclusions: This study contributes to a growing body of literature supporting the oncologic safety of omitting ALND in cN1 ypN0 pts treated with NAC, irrespective of the axillary staging approach. Technical limitations in identifying ≥3 nodes or localizing and retrieving CNs resulted in overtreatment with ALND in a significant proportion (≥15%) of ypN0 pts, without significant differences between SNB vs. TAD approaches. These data support consideration of re-evaluating NCCN guidelines recommending retrieval of ≥3 nodes and localization of the CN to minimize risk of overtreatment.