Three-dimensional automated breast ultrasound system (3D ABUS) is an innovation in breast ultrasound that has been developed to uncouple detection from image acquisition and to address the limitations of handheld ultrasound (HHUS). 3D ABUS provides a large field of view using high frequency transducers, producing high-resolution images and covering a large portion of the breast with one sweep. As more data become available on breast density and the impact of supplemental screening, 3D ABUS has gained wider acceptance as an adjunct tool to mammography. Computer-aided detection software significantly reduces interpretation time, improving the workflow for the utilization of 3D ABUS as a supplemental screening tool. In the diagnostic setting, 3D ABUS offers valuable impact in the detectability of breast lesions and the differentiation of malignant from benign lesions, with a high inter-observer agreement. State-of-the art technique, including uniform compression and proper positioning, tends to reduce artifactual posterior shadowing, while combined 3D ABUS-mammography interpretation improves radiologists’ diagnostic performance. Promising results have supported the enhanced efficiency of 3D ABUS in detecting the extent of breast cancer and assessing response to neoadjuvant chemotherapy, whereas its correlation with molecular subtypes of breast cancer is remarkable. Future perspectives include the integration of radiomics and deep learning in the further development of 3D ABUS.