INTRODUCTION:Soft tissue reconstruction around the knee is challenging from a functional and aesthetic perspective. While locoregional options remain limited, free flaps produce additional scarring and longer hospitalization. We describe the most distal "D-perforator" of ALT-axis and present our 4-year experience with a distal perforator-only propeller anterolateral thigh (D-POP ALT) flap for reconstruction around the knee. METHODS:Seventeen patients (7 males, 10 females, mean age 57 years), had distal perforator-only propeller (D-POP) ALT flap reconstruction of defects following the wide local excision of melanoma around the knee joint between May 2014 and December 2018. The most distal perforator in the line between spina illiaca anterior superior (SIAS) and the upper lateral border of patella was identified and marked with audible-Doppler and perforator-only propeller ALT (POP-ALT) flap, which was designed around it. Perforators were dissected intramuscularly or intraseptally to allow adequate flap mobilization, but no division of main pedicle was ever performed to ensure anterograde blood supply. Flaps were rotated into defects while all donor-sites were closed directly. RESULTS:The largest flap measured 25 × 6 cm. The perforator was found between 4 and 9 cm proximal to the upper lateral border of patella in all cases. It was found to be septal in 10 cases and intramuscular in 7 cases. Healing was uneventful in all cases, and patients were ambulatory immediately postoperatively. All patients were discharged on postoperative day 1. Excellent long-term outcomes were observed on follow-up by the senior author. CONCLUSIONS:In our experience, this technique is simple, reliable, and versatile. Thin and pliable flaps can be safely raised based on the most distal (D-POP) ALT perforator. In addition, sizeable flaps can be performed while still preserving the main ALT pedicle, if free flap is required for the same patient in the future.