First of all, another laryngoscopy and pharyngoscopy: The tumor in the area of the piriform sinus anterior wall, which is very difficult to adjust and evaluate, is revealed. This confirms the indication. The patient is transferred for neck dissection and tumor resection. First radical neck dissection on the right: typical skin incision. Exposure of the sternocleidomastoid muscle anterior margin and dissection of the lymph node fat package. Exposure of the omohyoid muscle and digastric muscle. A large lymph node metastasis is visible. This can be dissected from the internal and external carotid artery, as well as from the vagus nerve. The accessorius nerve runs into the node, the sternocleidomastoid muscle is also infiltrated and the internal jugular vein. Therefore, ablation of the internal jugular vein caudally and cranially, resection of the accessory nerve and resection of the sternocleidomastoid muscle. Preservation of the external jugular vein. Exposure and preservation of the hypoglossal nerve and superior thyroid artery. Inclusion of the capsule of the submandibular gland and surrounding nodes from level Ib. This results in an overall removal of level Ib and II to V. Now tumor resection: Entry into the pharynx at the level of the hyoid bone. For this purpose, the hyoid bone is first skeletonized and resected laterally over an area of 2/3 of the right half. The resection extends downwards to the tip of the piriform sinus. The aryepiglottic fold and parts of the postcricoid mucosa are resected medially. The tumor is thread-marked. A marginal sample is also taken from the cranial side and also sent to the frozen section marked with a thread. In the caudal frozen section, there is still carcinoma in situ in the margin. Therefore, another resection of a wide mucosal strip from the area from the arytenoid fold to the posterior wall of the hypopharynx is performed in this area. This is followed by another corresponding margin sample. This goes to the frozen section. No more tumor infiltrates here. Therefore, R0 resection can now be assumed. Now modified radical neck dissection on the left side: skin incision as on the opposite side. Exposure of fat lymph node package. Exposure of the omohyoid muscle, digastric muscle. Exposure of the internal jugular vein and its preservation. Exposure of the internal and external carotid artery, superior thyroid artery, hypoglossal nerve, vagus nerve and accessorius nerve. Development of the dorsal neck preparation while preserving the branches of the cervical plexus. The anterior neck preparation is removed, taking the submandibular gland capsule with it. This results in a level II to V evacuation. Subsequent tracheostoma creation: small Kocher collar incision. This is done in the area of the old scar. Exposure through scar tissue up to the thyroid gland. Apparently previous resection on the left. Isthmus is cut again and pushed to the side. Trachea is opened in the 1st/2nd intercartilaginous space. Small, broadly pedicled, modified Björk flap. Epithelialization of this in a typical manner. Insertion of a laryngectomy tube. Then elevation of the forearm flap from the left side: marking of the flap in a size of 8 x 6 cm. Mark the skin monitor. Angulate the arm and apply the tourniquet. Cut around the flap, initially close to the ulnar side. Here also expose the ulnar artery, then also radially. On the radial side, include the cephalic vein, which is contained in the subcutaneous tissue to the skin monitor. The radial artery is placed caudally and supplied with puncture ligatures. The flap is lifted subfascially with the pedicle in a typical manner. Small outgoing vessels are clipped. Connection of superficial/deep venous system in the elbow. Exposure of the outlet of the interosseous artery as well as the confluence and 2nd vein outlet. Deposition of the flap in the area of the cephalic vein, confluence and in front of the outlet of the interosseous artery. The artery is supplied with puncture ligatures. Flap vessels are flushed with heparin. A piece of full-thickness skin of the appropriate size is removed from the groin. After mobilizing the skin, the groin is closed in layers in a typical low-tension manner with the insertion of a Redon drain. Full-thickness skin is sutured into the defect in the forearm area and the forearm area is closed in layers in a cranial direction. A Vacuseal dressing and a stretcher splint are then applied. Suturing of the flap: The flap is sutured into the defect without tension using 3/0 Vicryl in single button sutures after sutures have been placed using the appropriate technique. The sutures are conditioned in each case. The superior thyroid artery is sutured to the radial artery using 8/0 Ethilon single-button sutures. After opening the clamp, good flow and good venous re-flow. The cephalic vein is connected to the external jugular vein with a 3/0 coupler after measuring. The medial antebrachial cutaneous nerve is connected to the superior laryngeal nerve with Ethilon 9/0 single button sutures to sensitize the flap. This is carried out after the nerve endings have been freshened. Final inspection shows good skin perfusion, good arterial flow, good venous return. The right side of the neck is closed by inserting the skin monitor. A Redon drain is also inserted here, which is secured with a suture. After irrigation, the left side of the neck is closed in layers with the insertion of a Redon drain. Laryngectomy tube is replaced by a cannula with a core, which is secured with sutures. The procedure is completed without complications. Patient goes to the intensive care unit for postoperative monitoring. Heparin perfusor started intraoperatively at 500 units per hour should be continued for 5 days. Antibiotics started preoperatively should be continued for 1 week. Postoperative feeding of the patient via PEG tube. Build up diet after swallowing porridge, from the 10th postoperative day at the earliest. Please check the flap postoperatively according to the schedule using Doppler and checking the skin monitor.  