Abstract: Pathologist performance of ultrasound-guided fine-needle aspiration (USFNA) is an exciting new practice frontier that has been gaining national interest during the last few years. Herein, I provide an introductory pictorial essay on how to perform the free-hand technique of USFNA. I have divided this “how-to” USFNA essay into a 4-step process starting with (1) echolocation of the target for aspiration; followed by (2) planning the needle approach to the target lesion; (3) placing the needle using ultrasound guidance, including discussion of both parallel and perpendicular approaches; and finally (4) documenting the target lesion and needle placement. Being proficient in palpation-guided FNA is a prerequisite for an easier transition to USFNA, and it will be assumed that the reader has at least some experience in palpation-guided FNA. Understanding the basics of ultrasound physics and instrumentation, attending a certification course on USFNA, and practicing USFNA on phantoms until the operation of the US machine and needle placement skills are automatic are essential minimal requirements that need to be achieved before making the transition to USFNA on patients.