Dedicated breast CT is a fully tomographic breast imaging modality with potential for various applications throughout breast cancer care. If implemented to perform dynamic contrast-enhanced (CE) imaging (4D breast CT), it could be useful to obtain functional information at high combined spatio-temporal resolution. Before developing a 4D dedicated breast CT system, a computer simulation method for breast CT perfusion imaging is proposed. The simulation uses previously developed patient-based 4D digital breast phantoms, and generates realistic images with the selected acquisition parameters, allowing to investigate the effect of different acquisition settings on image quality. The simulation pipeline includes all steps of the image generation process, from ray tracing and scatter map generation, to the addition of realistic resolution losses and noise models. The pipeline was validated against experimental measurements performed on physical phantoms with a dedicated breast CT system, in terms of average error compared to ground truth projections (6.0% ± 1.65%), Hounsfield unit (HU) values in a homogeneous phantom (acquired: -149 HU ± 2 HU; simulated: -140 HU ± 2 HU), signal-to-noise ratio (SNR) (average error 6.7% ± 4.2%), noise power spectra (NPS) (average error 4.3% ± 2.5%), modulation transfer function (MTF) (average error 8.4% ± 7.2%), and attenuation of different adipose/glandular equivalent mixtures (average error 6.9% ± 4.0%) and glandular plus iodinated contrast medium concentrations equivalent mixtures (average error of 9.1% ± 9.0%). 4D patient images were then simulated for different 4D digital breast phantoms at different air kerma levels to determine the effect of noise on the extracted tumor perfusion curves. In conclusion, the proposed pipeline could simulate images with a good level of realism, resulting in a tool that can be used for the design, development, and optimization of a 4D dedicated breast CT system.