Objective To discuss the clinical value of micro flow imaging （MFI） combined with real-time shear wave elastography （SWE） guided puncture in the precise diagnosis of BI-RADS type 4 breast nodules. Methods A total of 218 patients with breast nodules （224 nodules in total） admitted to the hospital from January 2020 to December 2024 were selected as the research subjects. MFI and SWE examinations were conducted to analyze the imaging features of benign and malignant breast nodules， evaluate the vascular blood flow grade and elastic hardness value of breast nodules， logistic regression was used to analyze the influencing factors of benign and malignant breast nodules， and analyze the diagnostic value of the two methods. Results All 224 nodules were pathologically confirmed， including 65 benign nodules and 159 malignant nodules. The number of malignant nodules with irregular morphology， incomplete edges and microcalcification was higher than that of benign nodules （P < 0.05）. The number of cases with blood flow grades 0 and I of malignant nodules was lower than that of benign nodules （P < 0.05）， while the number of cases with grades Ⅱand Ⅲ was higher than that of benign nodules （P < 0.05）. The SWE elastic ratio Eratio of malignant nodules was 3.25 ± 0.56， which was higher than that of benign nodules at 2.54 ± 0.22（P < 0.05）. The results of Logistic regression analysis showed that irregular nodule morphology， irregular nodule margins， microcalcification， MFI blood flow grade， and SWE elastic hardness value were all independent influencing factors for differentiating benign and malignant breast lesions （P < 0.05）. The consistency between the individual examinations of MFI and SWE and the pathological results was average （P < 0.05）， while the combined examination of MFI and SWE had a better consistency with the pathological results （P < 0.05）. The sensitivity， specificity， accuracy and negative predictive value of MFI combined with SWE in diagnosing benign and malignant breast nodules were higher than those of single detection （P < 0.05）. Conclusion MFI combined with SWE-guided puncture has a relatively high value in the precise diagnosis of BI-RADS type 4 breast nodules.