After the team time-out, the patient is positioned. Injection of local anesthetic with the addition of suprarenin in the neck and sterile abjoration. First, pharyngoscopy and laryngoscopy again: the exophytic tumor is seen, which starts below the tonsil lobe or former tonsil lobe and extends towards the posterior wall of the oropharynx, the lateral wall of the oropharynx, the base of the tongue and also down towards the hypopharynx. Clear indication for surgical resection with subsequent flap coverage using a microvascular graft. Now start with the tracheostoma placement. Skin incision over approx. 4 1/2 cm below the cricoid cartilage, dissection through the platysma, search for the pretracheal muscles and insertion in the median line. Push the muscles laterally. The cricoid cartilage and the trachea can be easily palpated. Now locate the upper pole of the thyroid gland and expose it. Successive transection of the thyroid gland from cranial to caudal using a bipolar and scissors. The thyroid lobes are bluntly pushed off, the trachea is now exposed. The incision is now made between the 2nd and 3rd tracheal clasp and a Björk flap is created while protecting the tube cuff. Suturing of the Björk flap and reintubation. Subsequent skin disinfection and sterile draping of all relevant surgical areas, including the pectoralis major areas. First start with neck revision on the left: Opening of the old scar. Exposure of the sternocleidomastoid muscle. The V. jugularis externa is preserved and ligated as well as beaten caudally. Subsequent laborious dissection of the cervical vascular sheath through the scarring. The internal jugular vein can be visualized, but without any branches. Some ligatures can be visualized. The internal and external carotid arteries are then visualized. The hypoglossal artery is completely connected to the carotid artery or the bifurcation and can only be mobilized with difficulty. The facial artery and the lingual artery can be preserved from the external carotid artery and can be beaten laterally after clipping. Successive isolation of the pharyngeal tube from caudal to cranial, dissection of the large cervical vessels cranially. The styloid process is also resected cranially. During dissection, the digastric muscle is also severed and the submandibular gland is removed in the typical manner, exposing the lingual nerve and sparing the branch of the mouth, which can be exposed over a short distance. Lymph nodes are removed cranially at the parotid gland and also around the submandibular gland as well as latrally in the area of level V and laterally IV, III and II. Some lymph nodes were also removed anteriorly. Finally, complete isolation of the pharyngeal tube from the large vessels. Hypoglossal nerve preserved. Subsequently, after insertion of mouth blockers, combined removal of the tumor from the inside and outside. Tumor is removed macroscopically with a safety margin of 1.5 cm, in some cases also 1 cm. The entire side wall of the oropharynx and most of the posterior wall is removed up to the beginning of the posterior wall of the hypopharynx, which is also partially removed. At the top, lateral resection of the mucosa up to the bone at the alveolar ridge, lateral part of the tongue body or base of the tongue is also resected, including the parts of the extrinsic musculature. This is then beaten outwards and released from the piriform sinus with a wide safety margin. In the area of the larynx, it can be seen that the tumor has grown up to the edge of the vallecula or the epiglottis and has also grown up to the thyroid cartilage. Therefore, resection of the base of the tongue and vallecula, including lateral parts of the epiglottis and lateral parts of the thyroid cartilage as well as the largest parts of the arytenoid fold. Resection extends to the middle level of the piriform sinus or just to the tip of the sinus. Marginal samples are also taken from the alveolar ridge and the base of the tongue, including the epiglottis and vallecula. In addition, marginal samples from the arytenoid region up to the piriform sinus and marginal samples from the adjacent arytenoid region up to the supraglottic region are taken. The tumor is thread-marked and sent for frozen section like all other marginal samples. In the area of the aryepiglottic fold and in the area of the arytenoid region to the subglottic region still partly carcinoma in situ. Maximum moderate dysplasia in the remaining area. Due to the advanced resection in the area of the larynx, a final, approx. 0.5 to 1 cm wide mucosal resection from the arytenoid region to the piriform sinus, whereby the postcricoid region is already resected. Another 0.5 to 1 cm wide resection from the supraglottic region including the arytenoid region. The arytenoid cartilage is now exposed, as is the aryepiglottic fold lateral to the larynx or supraglottic region. Both specimens are also marked remote from the tumor and sent for final evaluation. Further resections are no longer performed due to the significant threat of inability to swallow. Subsequent irrigation of the wound area and hemostasis. Now proceed to neck dissection on the right side. Here, skin incision exactly in the pre-existing scar from the mastoid to caudal towards the jugulum. Then cut through the subcutaneous tissue and the platysma. Then skin platysmal flap formation in the cranial anterior and caudal lateral direction, including the platysma. Subsequent exposure of the anterior edge of the sternocleidomastoid muscle. Massively scarred conditions. It can now be seen that the common carotid artery with the bifurcation lies directly on the sternocleidomastoid muscle. This is now dissected. The area of the bifurcation is heavily scarred. The internal jugular vein is no longer present in the case of previous surgery. Dissection along the weakly atrophied omohyoid muscle antero-cranially to the hyoid bone. Subsequent exposure of the posterior digaster venter muscle. Subsequently, sparse fatty tissue with hardly any lymph nodes is removed. The external jugular vein is also no longer present. However, 2 stronger veins can be found and dissected in the anterior triangle of the neck. The superior thyroid artery is also dissected 3 cm long after its exit from the external carotid artery. Further vascular dissection is then performed by <CLINICIAN_NAME>. Subsequent removal of the forearm flap: The size of the flap was measured beforehand. It is 11 x 8 cm and is planned three-dimensionally according to the requirements. Marking of the flap on the forearm. Curved skin incision up to the crook of the elbow. First cut the flap ulnarly. Lift the flap subfascially here. Ensure that some tissue remains on all tendons. Dissect cranially. Expose the superficial venous system, which shows a beautiful superficial vein with 2 ends in the area of the elbow. Connection to the deep venous system somewhat sparse but present. Then cut around the flap radially subfascially. Here, too, care is taken to ensure that tissue remains on the fascia. Distally, after clamping the radial artery and sufficiently long saturation over 98 to 100 %, the radial artery is removed and ligated with 4-0 prolene sutures as a through-layer ligature. The flap is then lifted along the pedicle. Small branches are clipped and bipolar coagulated. Successive tracing of the flap up to the olecranon. Here, transection of the interosseous artery after previous clamping with stable saturation. Then expose the confluence and radial artery. The vein is then removed and ligated. The artery is removed and closed with 6-0 Vascufil sutures. Flush the flap with heparin. The flap is then sutured into the defect. This is done without tension and completely except for a small remnant at the front of the tongue body. Adapting sutures are placed in the tongue body. An incision is made in the area of the larynx along the thyroid cartilage, an incision on the mucous membrane is not possible, as due to the................................. postcricoid mucosa, there is a risk of stenosis. Insertion sometimes with poor visibility and sometimes quite difficult. The stalk is now assessed with regard to connectivity. Conditioning of the radial artery and the two veins, whereby one of the cephalic veins, which is selected for the anastomosis, shows significantly thickened walls, even beyond the valve, and must be shortened. Subsequently, split skin is removed from the thigh with the dermatome, thickness approx. 0.8 mm. Starch is also applied to the wound area in the thigh and then a semi-permeable dressing is applied. Split skin is applied to the forearm without tension. Relief incision. A few swabs are sewn on to facilitate adhesion. Followed by Mepilex dressing. Wrapping with absorbent cotton and the application of some compresses. Then fitting of a Kramer splint and wrapping with an elastic bandage in a functional position. Positioning of the arm. Subsequent vascular suture. This is followed by anastomosis with the lingual and radial arteries. Suture with 8-0 Ethilon single-button sutures. Subsequent opening of the clamps, good arterial flow, good venous return. One of the cephalic veins is conditioned again for the venous anastomosis. In addition, the external jugular vein, which can be extended slightly by palpation. Here anastomosis with coupler 2.5. After opening the clamps good venous return, positive smear phenomenon. The 2nd of the cephalic veins is connected to a vein from the opposite side, which can be dissected from the submandibular gland in the sense of a facial vein and can be removed. After slight mobilization, this vein can be transferred to the left side through a tunnel that has been created and anastomosed with the second cephalic vein after appropriate conditioning using a 2.5 mm coupler. Here too, after opening the clamps, the smear phenomenon was positive. However, the pressure in the vein was slightly higher due to the lack of internal jugular vein on the right. Overall, difficult conditions as far as vessel preparation is concerned. Subsequently, the flap is well perfused. Extensive hemostasis and irrigation follows. Hemostasis of diffuse bleeding, especially on the left, is considerably more difficult and prolonged. Finally, the small diffuse bleedings were largely stopped and closed by inserting a Redon drainage and 2 flaps on the left. The forearm was primarily closed in the cranial area. Finally, insertion of a size 8 tracheostomy tube, which is fixed in the typical manner with sutures. Further inspection of the flap, which is well perfused. The procedure is completed without complications. The patient is admitted to the intensive care unit for postoperative monitoring. Please continue antibiotics for a total of 1 week. Nutrition via the PEG tube. After 12-14 days, gruel swallowing and, if necessary, diet build-up. A prolonged swallowing disorder is to be expected, in this case it is essential to plan a visit to the voice and speech department. Flap control clinically and by Doppler sonography typically for 5 days. Anticoagulation should be suspended until coagulation control, then restarted if necessary due to the diffuse bleeding tendency. Presentation at the interdisciplinary tumor conference is essential because the R situation is still uncertain; if there is still in situ carcinoma in the left laryngeal region, boost radiation should be discussed if necessary.