Induction of anesthesia and intubation by the anesthesia colleagues transnasally. Entry with the Kleinsasser tube and inspection of the tumor. The tumor starts in the area of the soft palate, moves to the tonsillar lobe on the right side, then from the tonsillar lobe to the base of the tongue and into the vallecula, from the vallecula to the epiglottis and from the epiglottis to the pharyngo-epiglottic fold on both sides, but on the right more than on the left, from the pharyngo-epiglottic fold to the pocket fold, on the right more than on the left. Injection and sterile washing and covering. Start with transoral tumor resection in the area of the soft palate. The monopolar needle, bipolar forceps and scissors are used for this. The tumor is released in the area of the soft palate and the tonsil lobe as well as partially at the base of the tongue. This automatically leads to the soft tissues of the neck, then switch to the neck, as the transoral view is no longer available. Now expose the sternocleidomastoid muscle. Expose the cervical vascular sheath and continue the tumor resection via a pharyngotomy from the outside. The tumor is dislocated outwards using the pull-through technique and resected en bloc on the right side and on the left side, taking two thirds of the hyoid bone and taking the epiglottis, vallecula and partial pocket fold with it. This resulted in a very large defect. The entire supraglottis had to be removed, leaving just the arytenoids on both sides and the vocal fold region. Now joint consideration of the next steps with <CLINICIAN_NAME>. Due to the extensive pharyngeal defect and the pending transplant, it does not make sense to preserve the rest of the larynx, as a pronounced permanent aspiration must be assumed. The vocal folds will also no longer be functional due to the narrow resection margins and the suturing to the graft. Hence the decision to remove the rest of the larynx and insert a Provox prosthesis. This is done in the usual way. Measurement of the defect 5 x 8 x 13 cm. The graft is configured in such a way that there is a bulge for the base of the tongue so that there is a sliding surface for tongue mobility later on. The graft is lifted from the forearm in the usual way using <CLINICIAN_NAME>. Lifting of the radialis graft on the left forearm by <CLINICIAN_NAME> and <CLINICIAN_NAME>: Marking of the skin graft on the distal forearm in the presence of <CLINICIAN_NAME>. S-shaped skin incision in the area of the proximal forearm up to the crook of the elbow and incision around the marked radialis graft. Visualization of the superficial venous system in the area of the S-shaped skin incision. A pronounced cephalic vein can be seen, which is traced and visualized from proximal to distal further to the radial flap edge. Dissection of the radial edge of the flap down to the deep forearm fascia and incision of this. Exposure of the external ramus of the radial nerve and protection of the nerve. Exposure of the brachioradialis radialis muscle. Ulnar skin incision down to the deep forearm fascia and incision of the fascia. Subfascial dissection leaving the peritendineum and perimysium intact. Distal skin incision and ligation of the superficial veins. Identification of the radial artery with the accompanying V. comitans. Blunt detachment from the vascular bed and clipping of the distal radial artery stump for approx. 5 minutes. A good perfusion signal is noted during this time. Then decide on distal pedicle transection and vessel ligation. Exposure of the extensor carpi radialis muscle. Dissection of the flap pedicle from the depth with constant hemostasis using vascular clips. The radial nerve can be spared well. Insertion of a retractor between the extensor carpi radialis and brachioradialis muscles. Vessel preparation up to the crook of the elbow. Insertion of <CLINICIAN_NAME> and exposure of the confluence. Separation of the radial artery just before the interosseous artery. Separation of the venous vessels at the superficial and deep venous system. This is followed by removal of an equivalent piece of split skin from the right thigh by <CLINICIAN_NAME> and <CLINICIAN_NAME>. Incision of the split-thickness skin graft in the usual manner. Sterile wound dressing. Application of a dorsal forearm splint. There was always a good perfusion signal during the operation. Neck dissection on both sides parallel to flap elevation. Start on the right side. Free preparation of the sternocleidomastoid muscle, the omohyoid muscle and the submandibular gland. The digastric muscle has already been dissected for the tumor resection. The hypoglossal nerve, accessory nerve and plexus branches can be spared. The facial vein cannot be spared. Remove the neck specimen II a to V a en bloc. Then turn to the opposite side. Here too, visualization of the sternocleidomastoid muscle, the omohyoid muscle, the submandibular gland and the digastric muscle. Exposure of the cervical vascular sheath, the accessorius nerve, the hypoglossal nerve and removal of the neck preparation II a to V a while sparing the plexus branches. The facial vein and another caudal vein branch from the internal jugular vein can be preserved here. Dissection and preparation of these two venous outlets and the superior thyroid artery for the flap connection. Suturing of the graft. To do this, start transorally in the area of the soft palate and the edge of the tongue as well as the alveolar ridge, then suture the rest of the graft transcervically. At the end, suture the anastomoses in the usual manner. Microsurgical insertion of two Redon drains and two-layer wound closure. Please continue antibiotics for at least 24 hours. Flap controls and presentation of the patient at the tumor conference after receipt of the histology.  