Written, informed consent for the publication of case details and identifying photographs and radiographs was provided by the patient. A 60 year old female presented to Head and Neck Clinic with a 3-4 month history of a lesion of the anterior alveolar ridge. Biopsies revealed invasive squamous cell carcinoma (SCC). Clinically, she had a 4 cm lesion of the anterior maxilla, and radiographically the tumor eroded just through the floor of the nasal cavity but did not approach the orbit. Her case was discussed at multidisciplinary tumor board, with consensus recommendation for upfront surgery via infrastructure maxillectomy. The patient was diagnosed with slowly progressive limb-onset familial ALS 3 years prior to this cancer diagnosis, with subsequent onset of respiratory and bulbar symptoms. At the time of presentation, she was wheelchair-bound, partially gastrostomy tube dependent (tolerating only limited pureed food by mouth), requiring symptom management for sialorrhea, and using NIPPV at night for orthopnea with normal speech function. Pre-operative pulmonary function testing showed a vital capacity of 51% of predicted normal. Given the underlying respiratory insufficiency due to her ALS, there was concern that the patient would be difficult to decannulate should she undergo tracheotomy perioperatively, and that by doing so she would be prematurely committed to lifetime tracheotomy dependence. The patient was admitted pre-operatively to optimize her overall status and evaluate if her NIPPV face mask could be incorporated post-operatively. Multi-disciplinary input between the surgical team, neurology, respiratory therapy, anesthesia, speech-language pathology, and patient resulted in a consensus decision to attempt to avoid a tracheotomy. The patient underwent an uncomplicated infrastructure maxillectomy, ipsilateral neck dissection, and fibula free flap reconstruction via a two-surgeon synchronous approach to minimize operative time. Two-segment vascularized bony reconstruction was utilized to reconstruct the anterior maxilla. The 5 × 10 cm fibula skin paddle was utilized for reconstruction of palatal, alveolar, buccal, and lip mucosa. The free flap pedicle was tunneled submucosally along the retromolar trigone, and medial to the mandible into the neck for microvascular anastomosis to the right facial artery and vein. A 3.0 mm venous coupler was utilized for the venous anastomosis. Total anesthesia time was 448 minutes. Immediately following extubation, the patient was transitioned to NIPPV pulmonary support with a Philips Respironics Total Face Mask (Murrysville, PA; Figure ). Following transfer into the intensive care unit, the patient was weaned from NIPPV to supplemental oxygen via facemask within 4 hour of transfer to the ICU, without need for positive pressure ventilation for the remainder of her inpatient stay. Throughout her immediate postoperative course, the free flap maintained excellent perfusion as evidenced by brisk capillary refill, appropriate color, and strong biphasic doppler signal on the skin paddle. There were no signs of venous congestion or partial or full skin paddle loss noted. At the time of outpatient follow up (POD 24), the skin paddle was well healed with all intraoral incisions intact, and the anterior maxilla displayed appropriate projection. The patient participated in a video swallow study on POD 24, revealing safe and efficient swallowing which allowed resumption of her pre-surgical diet of pureed foods and nectar thick liquids for pleasure. However, she remained partially G-tube dependent given pre-existing neuromuscular dysphagia.