Objective: To evaluate the impact of ALND and SLNB on upper limb (UL) morbidity in breast cancer patients. Summary Background: Axillary de-escalation is motivated by a desire to reduce harm of ALND. Understanding the impact of axillary surgery and disparities in operative procedures on post-operative arm morbidity would better direct resources to the point of need and cement the need for de-escalation strategies. Methods: Embase, Medline, CINAHL and PsychINFO were searched from 1990 until March 2020. Included studies were randomized-controlled and observational studies focusing on UL morbidities, in breast surgery patients. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The prevalence of upper limb morbidity comparing SLNB and ALND at less than 12 months, 12-24 months and beyond 24 months were analyzed. Results: Sixty-seven studies were included. All studies reported a higher rate of lymphedema and pain after ALND compared to SLNB. The difference in lymphedema and pain prevalence between SLNB and ALND was 13.7% (95% CI 10.5-16.8, p