First pharyngoscopy: The described tumor is seen, which occupies almost the entire palatal arch and extends caudally into the entire oropharyngeal side wall, growing into the base of the tongue. Hypopharynx: Lateral mucosal findings are clear. Therefore surgery with flap coverage confirmed. First injection of a total of 20 ml xylocaine 1% with adrenaline in the area of both sides of the throat. Then sterile draping. Start with tracheostoma creation: A small Kocher collar incision is made. Subsequent division of the infrahyoid muscles. Exposure of the thyroid isthmus. This is passed underneath, clamped off and then supplied with a puncture ligature. Exposure of the trachea. Entering the 2nd/3rd intercartilaginous space. Creation of a broad-based modified Björk flap. This is epithelialized. Insertion of a spiral tube. Subsequently combined transoral, transcervical tumor surgery and extended radical neck dissection on the left: First insertion of the McIvor mouth spatula and the mouth retractors in alternation and placement of a tongue retaining suture. The tumor is cut around on all sides with a safety margin of at least 1.5 cm. The entire palatal arch and anterior and posterior wall areas are removed. Resection extends over the alveolar ridge down to the base of the tongue. The floor of the mouth is incised forwards. The posterior half of the tongue body with the base of the tongue is resected close to the raphe. Marginal samples are taken from the entire palatal arch area, including the anterior and posterior wall, from the mucosa above the alveolar ridge, from the floor of the mouth in front, from the body of the tongue and from the base of the tongue. These are all tumor-free in the frozen section and have so far been R0 resected. The neck is then opened with a submandibular curved incision, which is extended caudally. It can be seen that the tumor has infiltrated the sternocleidomastoid muscle and extends cranially towards the base of the skull. There is also evidence of per-continuitatem growth of the tumor laterally to the uppermost lymph node stations. The external carotid artery can be dissected freely and is not infiltrated by the tumor in the lower part. The superior thyroid artery and thyrolingual trunk can still be preserved in the initial area. The facial artery must be sacrificed, as must the external carotid artery, which lies cranial to it. The internal jugular vein is removed caudally and cranially and ligated twice. The external carotid artery is resected in the area of the superficial temporal artery at the border to the entry into the parotid ligament and ligated twice. The internal jugular vein is removed at the entrance to the base of the skull and ligated twice. The hypoglossal nerve is infiltrated by tumor and must also be resected. The internal carotid artery and vagus nerve can be preserved. Accessory nerve is also resected. The sternocleidomastoid muscle is removed cranially. Resection with parts of the cervical plexus and the deep neck muscles if necessary to achieve complete removal in sano. The digastric muscle and submandibular gland are resected en bloc with the tumor in the sense of a pull through. As the operation progresses, it becomes apparent that, in addition to the per-continuitatem situation, there has also been a lateral invasion of the soft tissues of the hyoid bone. The pharyngeal wall is therefore lifted away from the prevertebral fascia. The hyoid bone is resected laterally. The upper part of the superior cornu is also resected. All soft tissues and the mucosa up to the piriform sinus entrance are resected. The posterior wall of the oropharynx and hypopharynx are resected in the necessary portion up to the oropharyngeal entrance up to half. A marginal sample is taken from the posterior wall of the pharynx up to the entrance of the piriform sinus. This is tumor-free, in the cranial area there are still questionable tumor infiltrates in small foci, approx. 1 cm below the tube area, which were partially resected. Another marginal sample was taken and then sent back for a frozen section. This is now tumor-free. A marginal sample is taken from the cranial basal soft tissue. No tumor infiltrates here either. An extensive marginal sample was taken from the caudal area, from the soft tissue at the base of the tongue towards the vallecula and the entrance to the larynx as well as the entrance to the piriform sinus. This is also tumor-free. Surgical resection can therefore now be assumed to be R0. The result is a defect from the tube to the hypopharynx, including the posterior wall of the oropharynx as well as the floor of the mouth, base of the tongue and the entire palate. The mandible was not infiltrated and the periosteum could be easily removed. The edge of the mandible at the angulus is chiseled off with a chisel to achieve a smaller transition and a better overview. All areas of the pterygoid muscle were also resected. The neck dissection on the left side was carried out including level I b and I a. Gland was also resected in the tumor. The lingual nerve and inferior alveolar nerve were also resected. Neck dissection left includes levels I to V. Neck dissection on the right side now follows. This is performed in a typical manner, including levels II to V. The defect is now covered using the anterolateral thigh flap: On the left side, a superior thyroid artery and the truncus thyrolingualis or terminal branch of the external carotid artery are available for vascular connection. The external jugular vein is available for the venous connection. This is followed by Doppler sonography in the anterolateral thigh area. Four perforators can be identified. The flap size was previously measured at 20 x 8 cm. A three-dimensionally configured thigh flap was measured and marked according to the defect. First, medial skin incision. Showing the rectus and vastus lateralis muscles. The ramus descendens can be dissected between these muscles. Then dissect the flap from the lateral side, also subfascially. Caudally dissect the vascular pedicle and ligate it. Successive development of the flap with inclusion of parts of the vastus lateralis muscle corresponding to the course of the perforators. Dissection in the direction of the exit from the profunda femoris artery. The artery and vein are removed here. Arterial and venous stumps are each treated with puncture ligatures. The primary closure is then performed in a typical low-tension manner with the insertion of a Redon drain. The thigh flap is inserted transcervically into the defect and sutured in place with relatively little tension using 3.0 single Vicryl button sutures. The complex defect is covered from the floor of the mouth via the base of the tongue, pharyngeal wall and the entire palatal arch with minimal tension. The flap vessels and the external jugular vein are then conditioned, as is the terminal branch of the external carotid artery, which is selected for flap anastomosis. Vascular suturing is performed with 8.0 ethilon sutures between the external carotid artery, terminal branch and descending ramus. After opening the clamp, good arterial flow and good venous return. Venous anastomosis between the common terminal flap vein and the external jugular vein after measuring with a Coupler measuring device using a 4/0 Coupler. Good venous return, positive smear phenomenon. Now follows layered wound closure on the right cervical side with insertion of a Redon drain. Left cervical with insertion of a flap. Epithelialization of the tracheostoma and insertion of an 8.0 tracheal cannula. Marking of the course of the flap pedicle for postoperative Doppler control. Checking the flap enorally shows a well-perfused flap. Completion of the procedure without complications. Patient goes to the intensive care unit for postoperative monitoring. Please continue antibiotics with Unacid for 1 week. Feeding via PEG for at least 10 days, then gruel and, if necessary, diet build-up. Heparin perfusor for 5 days ......... per hour. Regular Doppler checks according to the scheme and enoral flap checks. Overall cT4 cN2c multistage carcinoma, postoperative RCT certainly required.