Summary: Cervical exenteration with anterior mediastinal tracheostomy is rarely performed for extensive cervicothoracic malignancies. Although it provides effective palliation and occasional cure, reconstruction remains a formidable challenge owing to its complexity and high mortality. The resultant defects usually require an intestinal flap or tubed skin flap to restore the alimentary tract, soft-tissue interposition to separate the relocated trachea from the innominate artery, and another tubed or fenestrated skin flap to create a tension-free tracheocutaneous anastomosis and provide coverage for the exposed vessels, hopefully in one stage. We report a case involving a 60-year-old woman with recurrent medullary thyroid cancer who developed dyspnea and dysphagia. Salvage cervical exenteration and anterior mediastinal tracheostomy were complicated by tissue fibrosis caused by previous surgical and radiation therapies, resulting in complex defects with segmental loss of the esophagus, a short stump of trachea incapable of tracheocutaneous anastomosis, and great-vessel exposure. We used a chimeric anterolateral thigh flap consisting of a tubed skin flap for pharyngoesophageal reconstruction, a fenestrated skin flap for tracheostomy and neck coverage, and a vastus lateralis muscle bulk to separate the innominate artery from the relocated trachea. To our knowledge, this is the first report describing the reconstruction of such a complex defect with a single skin flap in a single stage.