As tomosynthesis is rapidly adopted by breast imaging practices, tomosynthesis-guided procedures are increasingly being performed. Tomosynthesis-guided needle localizations are feasible and efficient and allow for localization of tomosynthesis-only findings or one-view findings, which may be difficult to localize under standard digital mammography. In this review, we describe our step-by-step approach for performing tomosynthesis-guided localizations of the breast and axilla using a standard tomosynthesis unit.