First, pharyngoscopy and laryngoscopy again: The exophytic tumor is seen in the area of the entire palatal arch with transition to the tonsillar lobe on the right and extending to the tonsillar lobe on the left. Initial PEG insertion: insertion of the flexible esophagoscope into the stomach. After creating the diaphanoscopy, a 9 mm abdominal wall tube is inserted in a typical manner without complications. Fixation to the abdominal wall. Sterile dressing. Then transoral tumor resection: insertion of the Mc Ivor oral spatula. The carcinoma is removed en bloc with the electric needle with a safety distance of at least 1.5 cm on all sides. The tonsil and parts of the pharyngeal wall are resected, especially on the right side; on the left side, the upper part of the tonsil pole and pharyngeal wall area are also resected. The specimen is thread-marked and sent for frozen section diagnosis. Here the margins are tumor-free and therefore R0 situation. Subsequent radical neck dissection on the left and modified radical neck dissection on the right: start on the left side. Curved skin incision in front of the sternocleidomastoid muscle. Lymph node tumor masses are visible which have infiltrated the sternocleidomastoid muscle, as well as the accessorius nerve. The internal jugular vein is also included. Dissection is performed from medial to lateral, hypoglossal nerve, common carotid artery as well as internal and external carotid artery are exposed and preserved, vagus nerve as well. Neck preparation is removed with resection of the accessorius nerve, sternocleidomastoid muscle and internal jugular vein. Branches of the cervical plexus are preserved as far as possible and appropriate. The internal jugular vein is double ligated cranially and caudally. This results in a radical neck dissection. Now neck dissection on the right side: here too, clearly positive lymph nodes, especially in the cranial region. The sternocleidomastoid muscle, omohyoid muscle and digastric muscle are visualized. Exposure of the cervical vascular sheath, internal jugular vein and common carotid artery as well as internal and external carotid artery. Subsequent visualization of the vagus nerve and accessorius nerve. Development of the dorsal neck preparation while preserving the branches of the cervical plexus. Then develop the medial neck preparation, exposing and preserving the hypoglossal nerve, superior thyroid artery, facial vein and inferior thyroid vein. The external jugular vein was also preserved. The defect was then measured enorally. Now removal of the radial flap: marking of the radial flap in the required design, total length 11 cm and max. width 6 cm. Marking of the skin monitor. Cut around the skin monitor and radialis flap. Subcutaneous tissue is preserved over the subcutaneous tissue between the skin monitor and radialis flap. Curved skin incision up to the crook of the elbow. Radialis flap is now lifted from first ulna, then also radial subfascial. The radial artery is exposed and ligated. The lateral antebrachial cutaneous nerve is exposed and preserved. Successive elevation of the radial artery flap below the vascular pedicle and subfascially in the direction of the elbow bend. Removal of subcutaneous tissue including the superficial and deep venous system in the upper area. Smaller and larger vessels are supplied with clips or bipolar coagulation or alloying. Exposure and confluence of the superficial deep venous system in the antecubital fossa, which finally flows together in a large antecubital vein. Exposure of the radial artery. Separation of radial artery and vein. Supply of the proximal vessels using clips or ligatures. Full-thickness skin is removed from the groin area in a size corresponding to the forearm defect. Here, after hemostasis, the wound is closed in layers and a Redon drain is inserted. The forearm is closed directly proximally and the full-thickness skin graft is successively inserted distally. A Vacuseal dressing with 125 mmHg suction is then applied. The defect of the palatal arch defect is now covered using the radial flap: First, a 2 - 3 finger wide tunnel is created through the pharyngeal wall to the right side of the neck. Then pass the flap from transcervical to enoral. Successive suturing of the flap first dorsally, then ventrally at the palatal arch. Complete closure of the defect from the transcervical side using sutures. This results in tension-free closure of the defect. The skin monitor is sutured to the neck skin. Vessels of the flap pedicle are dissected. The superior thyroid artery is removed and freed from the ...... The superior thyroid artery is anastomosed end-to-end with the radial artery using 8.0 ethylene sutures. Good arterial flow after opening the bulldog clamp. Venous return flow clearly recognizable, but intermittent due to arterial positions. Subsequent selection of the facial vein for the anastomosis. After dissection of the vessel wall, removal of the facial vein. Measuring. Selection of a 3.5 mm coupler. Anastomization of the vein of the flap pedicle with the facial vein using the 3.5 mm coupler. Good flow after opening the vessels. Upright test positive. Good enoral aspect. Finally, irrigation of the entire wound area. Wound closure in layers with insertion of a Redon drain in the left side of the neck. Finally, placement of a tracheostoma in the typical manner. This is carried out in the 2nd/3rd intercartilaginous space via a broadly pedicled, visor-like Björk flap. Epithelialization of this. Insertion of an 8 mm tracheostomy tube. This is fixed with sutures. The procedure is now completed without complications. Finally, marking of the sites for postoperative vascular Doppler checks. Patient goes to the intensive care unit for monitoring. Please continue the antibiotic treatment started with Unacid i.v. for 1 week. Feeding via the inserted PEG tube for 7 - 10 days, followed by a diet. Overall cT2 - 3 cN2c palatal arch/oropharyngeal carcinoma. Postoperative RCT indicated.