The patient is a 76 year old man with history of T2N1 p16+ SCC of the right tonsil. He was initially treated with concurrent chemotherapy and radiation (CRT). The patient had recurrence and underwent robotic radical tonsillectomy. The patient developed a second recurrence at the previous resection site. The surgical plan to manage this second recurrence included: tracheostomy, right oropharyngectomy, median mandibulotomy, right neck dissection levels I-IV, and free flap reconstruction using right ALT flap. The ALT flap contains skin, subcutaneous fat, fascia of the thigh along with the vascular pedicle, the descending branch of the lateral circumflex femoral artery and veins. Raising this fasciocutaneous flap requires meticulous intramuscular dissection to follow the perforating vessels from the skin to the main pedicle. The flap itself is thin, pliable, low profile, with a potentially large surface area, making it an ideal choice for reconstruction of large defects in the head and neck region. The flap has a long vascular pedicle allowing easy reach to various potential recipient vessels, which gives it versatility during flap inset. The ALT flap was raised and isolated on its pedicle. It was brought up to the defect and tentatively inset with the pedicle extending through the right floor of mouth to the recipient facial artery and vein. The vascular anastomosis was completed, hand sewing the artery with 8-0 nylon and coupling the vein with a 2.5mm coupling device. The inset was completed off ischemia time. The patient had an uneventful post-operative course and is currently disease-free.