Induction of anesthesia and intubation by the anesthesia colleagues. Sterile washing and draping of the neck area and performance of a tracheotomy by <CLINICIAN_NAME>. Transverse skin incision for this, which can later be extended to form an apron flap. Exposure of the musculature. Splitting of the musculature in the midline. Exposure of the thyroid isthmus. Dissection of the thyroid isthmus. Exposure of the anterior wall of the trachea. Entering the trachea between the second and third tracheal cartilages. Intubation onto an LE tube. Sterile washing and draping. Applying an apron flap in the usual manner and performing neck dissection in parallel on the right and left. Neck dissection on the left: This shows a huge metastasis in level II infiltrating the sternocleidomastoid muscle, the internal jugular vein, the hypoglossal nerve and the accessory nerve and parts of the cervical plexus as well as the marginal ramus of the oral branch and also parts of the lower pole of the parotid gland. First expose the anterior border of the sternocleidomastoid, then the omohyoid and the submandibular gland. Insertion of a blocker and exposure of the cervical vascular sheath. Then dissection of the cervical vascular sheath up to the tumor. Separation of the internal jugular vein. Removal of most of the sternocleidomastoid muscle. Separation of the digastric muscle, which is also infiltrated. Severing of the hypoglossus, which is also drawn into the metastasis. It can now be seen that the external parotid artery is also being drawn into the metastasis. Showing the internal carotid artery. This can be completely detached from the metastasis. Separation of the external carotid artery and removal of the neck specimen including the metastasis. The left side is therefore not suitable for performing a flap connection. Neck dissection on the right side, after creation of the apron flap: Dissection of the skin platysmal flap sharply with the scalpel. The jugular vein is exposed, ligated, cut and dissected further cranially and preserved. Dissection along the anterior edge of the sternocleidomastoid muscle in depth. The accessorius nerve is now exposed and spared. The accessor nerve is followed further cranially and the posterior belly of the digastric muscle is now also visible. Further medially, the submandibular gland can be seen, which is also easily visualized. The omohyoid muscle can be seen caudally. This shows the borders of the neck dissection. The cervical vascular sheath is visible in the depth below the neck preparation. The internal jugular vein is exposed from caudal to cranial. There is no injury to the structures here. The superior thyroid vein and facial vein are dissected and spared. Medial to the jugular vein, the common carotid artery, the external carotid artery, the vagus nerve and the cervical artery are exposed. The neck preparation is now detached in level II b. Level II a follows, sparing the accessorius nerve. Levels III/IV and V are also detached without difficulty. The plexus branches are visualized and specifically spared. No chyle fistula occurs caudally when the neck preparation is removed. The anterior neck preparation is now also exposed and dissected along the facial vein and the superior thyroid vein. Clinical cN0 neck status. The tumor is now resected from the transcervical area, but half of the hyoid bone must also be resected. The tumor is incised around the edge of the tongue, then in the base of the tongue, then dislocated cervically and the rest is dissected out here. The tumor is placed on a cork and then cut out as a whole. All edges are tumor-free. Moderate dysplasia at the base of the tongue. This is resected again with a corresponding margin sample. Both are sent for final histology. Then measurement of the defect and preparation of the radialis graft by <CLINICIAN_NAME>. In the meantime, dissection of the vessels on the right side by <CLINICIAN_NAME>. There is a well-branched facial vein and a slightly deeper outlet from the internal jugular vein that is well suited for venous vascular connection. The superior thyroid artery is then dissected, which could serve as an arterial vascular connection. Enter with the flexible gastroesophagoscope and insertion of the PEG through <CLINICIAN_NAME> and <CLINICIAN_NAME>. Entering with the gastroesophagoscope and, with air insufflation, pre-scanning into the stomach. Once in the stomach, endoscopy of the cardia after inversion of the endoscope. A spontaneous diaphanoscopy is now seen. A PEG is now placed in loco typico on the left paramedian anterior wall of the stomach using the suture pull-through method. This was performed without any problems. The patient received Unacid 3 g i.v. perioperatively. Measurement of the defect and the three-dimensional configuration. The resulting flap size is 14-15 x 10 cm, with one end becoming two-cornered. Now radial flap elevation. Mark the flap on the left forearm. Then first make an ulnar incision and extend the incision in the crook of the elbow. Elevation of the flap from the ulnar side. Then expose the superficial venous system and the connection to the deep venous system. Two cephalic veins can be dissected first. Cut around the flap radially. This is lifted subfascially as well as ulnarly, leaving tissue on the fascia. The lateral antebrachial cutaneous nerve is exposed and preserved. The radial artery is then exposed. After adequate clamping time, whereby the saturation here was constantly at 100 %, this is removed, cut and treated using 4.0 prolene sutures. Lift the flap subfascially along the pedicle. This must be separated by the brachioradialis muscle. Smaller vessels are clipped or supplied with bipolar. A confluence with two larger ends is also prepared in the area where the radial artery enters the brachial artery. This is removed, theoretically leaving two ends for the anastomosis. The veins are then removed and ligated proximally. The artery is removed and treated using 6.0 Vascufil single-button sutures. Removal of the flap and irrigation with heparin solution. A piece of split skin measuring 15 x 7 cm is easily removed from the right thigh using the dermatome. Due to the size of the defect, after demonstrating the findings on <CLINICIAN_NAME>, another piece of skin is removed, measuring 8 x 8 cm from the thigh ............laterally. This is done without any problems. Dressing with starch powder and Mepilex. Suture the flap into the defect. The flap is successively sutured into the defect, sometimes with sutures. This is achieved without tension. Prior to this, infrahyoid muscles were pedicled at the left superior thyroid artery and lifted and mobilized as a Remmert flap while preserving the innervation as far as possible. After soft tissue preparation, the pedicle is pulled through under the mobilized Remmert flap and inserted into the right side of the neck. Here, the artery and three veins of the flap are conditioned first, a confluent vein and the two cephalic veins. The superior thyroid artery is then conditioned. This is incised slightly so that the lumen fits better with the lumen of the radial artery. Suturing using 8.0 Ethilon single-button sutures. After opening the clamps, very good arterial flow and good venous return. Conditioning of the veins. The thyroid vein is removed with two ends. The proximal ends are clipped. The two ends are each anastomosed with the confluent vein or one end of the cephalic veins with a 2.5 mm coupler after appropriate conditioning. After opening the clamps, good venous flow, positive smear phenomenon. The facial vein is then prepared. A small outlet is selected for the anastomosis with the second cephalic vein. This is also done using a 2.0 coupler. Here too, after opening the clamps, good venous return, positive smear phenomenon. The proximal end of the facial artery is first clipped and then ligated. Careful irrigation of the entire wound area and hemostasis are now performed. The Remmert flap is now inserted into the former tongue base area on the pedicle to create volume augmentation and fixed in place using several 3.0 Vicryl single button sutures. Subsequent irrigation and hemostasis. Inspection of the flap enorally, it is vital and well supplied with blood. The wound is now closed in layers, with insertion of a Redon drain on the left and two flaps on the right and epithelialization of the already created tracheostoma. For this purpose, the laryngectomy tube is removed and the size 8 tracheostomy tube is inserted and then fixed in place using sutures. A suture is placed on the right above the vascular pedicle at skin level to facilitate blood flow by means of Doppler monitoring. Inspection of the flap again. This is vital. The procedure is then completed without complications. The patient is ventilated and transferred to the intensive care unit. Please continue the intraoperative antibiotic treatment with Unacid for one week. Flap control according to the scheme for 5 days, clinically and by means of Doppler control every 2 hours. Nutrition via PEG tube for at least 10 days. Then X-ray pre-swallow and, if necessary, diet build-up. Overall cT3-4 oropharyngeal carcinoma on the left with cN2c status. Awaiting final histology and then presentation at the interdisciplinary tumor conference. Prolonged disturbance of swallowing function is to be expected. In this case, even after an unremarkable swallow, presentation to the voice and speech department or swallowing training on the ward.  