Objective The present study was performed to assess the accuracy and clinical value of image-guided vacuum-assisted breast biopsy in the diagnosis of mammography-detected breast microcalcifications. Methods This prospective study involved 100 patients with suspicious mammography-detected microcalcifications who underwent image-guided vacuum-assisted breast biopsies from January 2013 to October 2016. Stereotactic vacuum-assisted breast biopsy (SVAB) was performed in 64 patients, and ultrasound (US)-guided vacuum-assisted breast biopsy (US-VAB) was performed in 36 patients in whom application of SVAB was difficult. The microcalcifications were detectable by mammography or US. The mean follow-up duration was 32 months (range, 9-57 months). The biopsy results were correlated with the pathological examination results. Results The positive predictive value of microcalcifications detected by mammography and US in the diagnosis of breast cancer was 37.0% (37/100) and 52.8% (19/36), respectively. The negative predictive value of microcalcifications detected by US in the diagnosis of breast cancer was 71.9% (46/64). No recurrence was observed in the 37 patients with breast cancer. No evidence of malignancy was found among the 63 patients with benign lesions. Conclusion Image-guided vacuum-assisted breast biopsy is accurate and minimally invasive. It can be used as a safe approach for diagnosis in patients with breast microcalcifications.