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The purpose of this study was to evaluate perfusion-related complications in bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction based on perforator selection.A retrospective review of a prospectively maintained database was performed on all patients undergoing bilateral DIEP flap reconstruction at a single institution between 2004 and 2014. The hemiflaps were separated into three cohorts based on perforator location: lateral row only, medial row only, and medial plus lateral rows. Postoperative flap-related complications were compared and analyzed.There were 728 total hemiflaps: 263 (36.1 percent) based on the lateral row, 225 (30.9 percent) based on the medial row, and 240 (33.0 percent) based on both the medial and lateral rows. The groups were well matched by perforator number and flap weight. Fat necrosis occurrence was significantly higher in flaps based solely on the medial row versus lateral row perforators (24.5 percent versus 8.2 percent; p < 0.001). There was no statistically significant difference in fat necrosis between flaps based only on the lateral row versus flaps based on both the medial and lateral rows (8.2 percent versus 11.6 percent; p = 0.203). Generally, within the same row, increasing the number of perforators decreased the incidence of fat necrosis.Perforator selection is critical for minimizing perfusion-related flap complications. In bilateral DIEP flaps, lateral row–based perforators result in significantly less fat necrosis than medial row–based perforators. The authors’ data suggest that the addition of a lateral row perforator to a dominant medial row perforator may decrease the risk of fat necrosis.Therapeutic, III.