Background and Hypothesis Triple-negative breast cancer (TNBC) patients are at increased risk for recurrence compared to other subtypes of breast cancer. Previous evidence showed that adiposity may contribute to worsened cancer control. Current measures of obesity, such as body-mass index (BMI), are poor surrogates of adiposity, while visceral-to-subcutaneous adiposity ratio (VSR), which can be measured from routine computed tomography (CT) imaging, is a direct adiposity measure. We hypothesized that VSR is a stronger predictor of recurrence compared with BMI in patients with TNBC. Materials and Methods This study includes 162 women with stage I-III TNBC who completed standard of care therapy. Measures of body composition, including VSR, visceral adiposity (VA), and subcutaneous adiposity (SA), were estimated using a semi-automated quantitative imaging tool on CT images of the abdomen at the level of L2-L3. Anthropometric measures included BMI and waist circumference and were obtained from CT images. Associations of adiposity measures and recurrence risk were assessed using Fine and Gray competing risk models with death as a competing risk and age at diagnosis and clinical disease stage as covariates. Results During a median follow-up time of 3.6 years, 55 patients had recurrence. The median BMI at baseline was 30.2 [Quartiles: 26.3-35.2]. Body composition was not associated with overall or locoregional recurrence. VSR was significantly associated with an increased risk of distant recurrence, with a subdistribution hazard ratio of 4.25 (95% CI: 1.06-17.02), p = 0.041. By contrast, BMI was not associated with any recurrence risk. Conclusion Consistent with our hypothesis, VSR was associated with a significant risk of distant recurrence and therefore may be a prognostic biomarker. Future directions include interventions targeting VSR reduction among patients with TNBC and VSR-directed therapy modulation.