Abstract Background: Recent advances in technology have prompted growth in the surgeon’s armamentarium for breast biopsy. For nonpalpable, mammographically detected lesions, the options include stereotactic needle/wire localization and open biopsy (SNL/OBx), stereotactic needle core biopsy (SNCB), and directional, vacuum-assisted biopsy (VAB; Mammotome). Methods: A review of 372 patients with 424 breast lesions biopsied by the same surgeon between January 1993 and August 1997 was performed. Results: SNCB and VAB procedures were less invasive and less morbid than SNL/OBx. Vacuum-assisted biopsy was superior to SNCB for sampling efficiency, with 74% of microcalcifications removed compared with 20% ( P <0.0001). Additionally, underestimation of disease was seen with the SNCB technique, but not with VAB. Follow-up mammography found no false negative biopsies in any group. Over the 56 consecutive months, VAB progressively replaced SNL/OBx and SNCB as the procedure of choice. Conclusion: A breast surgeon can use VAB to replace open biopsy and core needle procedures for the initial biopsy of nonpalpable breast lesions.