First, after preparation by the anesthesia colleagues, the primary tumor region is inspected. An ulcerated tumor is found in the area of the soft palate with a depleted uvula. Infiltration of the right tonsil. Here infiltration beyond the tonsil capsule, laterally. The caudal tonsil pole is exceeded by palpation. In addition, clear infiltration on the right side of the posterior palatal arch up to the transition to the posterior pharyngeal wall. On the left side, the carcinoma moves to the left tonsil, does not infiltrate it palpatorily via the hianus capsule, but here too there is clear infiltration of the posterior palatal arch, also with transition to the posterior pharyngeal wall. The transoral procedure is now performed. Incision in the area of the mucosal level of the tumor with subtotal removal of the soft palate. Complete removal of the anterior left palatal arch in the sense of a tumor tonsillectomy. Release of the tonsil at the lower tonsil pole. No transgression of the tonsil capsule laterally, safe basal conditions here. Inclusion of the posterior palatal arch. Resection up to the posterior pharyngeal wall is necessary. Right-sided extended resection. Resection up to the parapharyngeal soft tissue of the neck. This ensures safe conditions basally. Resection caudally up to the entrance of the piriform sinus. Resection of the posterior palatal arch also up to the posterior wall of the oropharynx so that only a mucosal strip of approx. 3 to 4 mm remains in the area of the posterior wall of the oropharynx. Retraction of the soft palate. It can now be seen that the tumor is clearly infiltrating cranially via the posterior surface of the posterior palatal arch. Therefore extension of the resection. Resection down to the hard palate. Cut off the posterior edge of the maxilla down to the choanae and the posterior edge of the septum. For reasons of overview, the main tumor is removed first and isolated to the cranial part. Form a post-resection by removing the posterior edge of the maxilla as described above. Resection up to the tubal bulges. The ostia remain intact. Complete covering here in the nasopharyngeal region in the area of the mucosal settling margins. Otherwise, take marginal samples from the specimen. The specimen is thread-marked for definitive histology. Marking of the separated tumor portion, otherwise macroscopic in sano resection on the specimen. Complete covering of the tumor with margin samples as far as possible. In this case, frozen section diagnostics show an in sano resection for the invasive carcinoma. Only in the area of the margin in the area of the left lateral tonsillar lobe is there a CIS and in the area of the posterior pharyngeal wall a suspicion of CIS as well as moderate dysplasia. A resection was performed in the area lateral to the left tonsil and covered with a new marginal specimen, which was found to be tumor-free. Due to the circumscribed pharyngeal remnant and the proximity of the tumor, the decision was made to completely resect the posterior pharyngeal wall and preserve the prevertebral fascia. After confirmation of the N0 situation, the neck is first dissected on the right side. To do this, make an incision on the anterior edge of the sternocleidomastoid muscle. Exposure of the sternocleidomastoid muscle, omohyoid muscle, submandibular gland and digatric muscle. Exposure and preservation of the external jugular vein, internal jugular vein, facial vein, superior thyroid artery, cervical artery, hypoglossal nerve. Exposure of the common carotid artery and vagus nerve. Clearing of the accessorius triangle with careful protection of the nerve and completion of level V with careful protection of the cervical plexus branches. Macroscopically conspicuous nodes in level II, otherwise macroscopically inconspicuous site. If the wound is dry, the tracheotomy is then performed. The skin incision is made horizontally below the cricoid cartilage. Cut through skin and subcutaneous tissue. Exposure and transection of the infrahyoid muscles. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. Dissection of the thyroid isthmus. Due to the height of the larynx, insertion between the 1st and 2nd tracheal ring. Formation of a visor tracheotomy and incision of the skin in the typical manner. Subsequent intubation onto a tube. At the end of the procedure, reintubation onto a size 8 low-cuff cannula, which is suture-fixed. The anterolateral thigh graft is now lifted from the right after doppler sonographic identification of the main perforator and a secondary perforator. The graft, measuring 17 x 8 cm in total, is marked. Medial incision. Cut through skin and subcutaneous tissue. Cutting through the fascia lata. Exposing and securing the rectus femoris muscle. Subfascial dissection. Identification of the pedicle vessel. Subsequent identification of the main perforator. Dissection of the perforator down to the pedicle vessel with musculocutaneous perforator course. In the area of the perforator junction, leave the fascia lata on the graft, otherwise leave in situ. Complete resection and release. Isolation on the perforator and the pedicle vessel. Subsequent removal of the excellent vital graft after supplying the feeding and draining vessels. Careful monitoring of the thigh area and, if the wound is dry, insertion of a 10 Redon drain and careful multi-layer wound closure with adaptation of the skin edges. The combined transcervical and transoral insertion of the graft is now performed. The conditions here are considerably more difficult due to the extensive defect. Finally, however, good reconstruction. In the area of the posterior pharyngeal wall, the graft is sutured to the prevertebral fascia and a narrow exposed margin is left here. Good reconstruction of the soft palate and the nasopharyngeal section. Intact conditions on all sides. Stalk positioning to the right cervical side, after previous creation of a tunnel measuring approximately 3 transverse fingers. The superior thyroid artery is then dissected and conditioned. Perform the arterial anastomosis with 8.0 Ethilon. This works well. Immediate venous return via both draining veins. First condition the facial vein. Perform the anastomosis with the coupler system. If there is still clear venous return via the second vein, the second vein is anastomosed to the external jugular vein, also using the Coupler system. Subsequently, a regular pedicle position and a positive spreading phenomenon and vital graft enorally, so that a 10 Redon drain is then inserted and the wound is carefully closed in two layers. Neck dissection on the left side. The skin incision here corresponds to the opposite side. Cut through skin and subcutaneous tissue. Exposure of the sternocleidomastoid muscle, omohyoid muscle. Release of the submandibular gland. Exposure of the digastric muscle. Dissection of the internal jugular vein, facial vein, superior thyroid artery, cervical artery, hypoglossal nerve. Exposure and clearing of the accessorius triangle with careful protection of the nerve. Exposure of the internal jugular vein, vagus nerve and common carotid nerve and evacuation of level V with careful protection of the cervical plexus branches. If the wound is dry, insertion of a 10-gauge Redon drain. Subsequent careful two-layer wound closure and completion of the procedure with a vital graft and no indication of complications. Conclusion: Extensive growing cT3 cN2c oropharyngeal carcinoma on both sides with discrete right emphasis. Due to the extensive defect, initial feeding via the existing PEG tube for at least 8 to 9 days. If the graft heals properly, a gradual increase in nutrition can then take place; if necessary, a prolonged recovery of swallowing function can be expected due to the extent of the defect. Presentation at our interdisciplinary tumor conference to determine the extent of adjuvant therapy.