<CLINICIAN_NAME>: After induction and intubation by the anesthesiology colleagues, the primary tumor region was first inspected for extensive cervical metastasis with broad skin infiltration and a clear inflammatory reaction in the surrounding area. Overall, the mass was partly necrotic and appeared liquid, measuring over 10 cm in total. The Kleinsasser tube was inserted under dental protection and the inconspicuous oral cavity and oropharynx were inspected. An uneven mucosa can now be seen at the entrance to the left piriform sinus, which merges into an ulcerated tumor in the area of the left piriform sinus. The uneven and partly slightly elevated mucosa moves to the posterior wall of the hypopharynx, just not reaching the midline and caudally free esophageal entrance. The tumor infiltrates the hemilarynx via the medial piriform sinus wall and breaks through it here and appears submucosally in the area of the pocket fold. The glottic plane itself and the subglottic region are exposed. The patient is now repositioned and prepared. Incision of the monstrous mass on the left cervical side with sufficient safety distance, completion of the incision to the right in the sense of an apron flap. Dissection of the healthy skin in the form of an apron flap. Detachment of the mass which broadly infiltrates and destroys the sternocleidomastoid muscle, also resection in case of infiltration of the omohyoid muscle. Caudal visualization of the cervical vascular sheath. The internal jugular vein can already be seen here with significantly reduced flow, with clear infiltration cranially. This is therefore removed. Exposure and preservation of the common carotid artery and vagus nerve. Cranially, the mass also infiltrates the submandibular gland and the digastric muscle. Sectional exposure of the ramus marginalis mandibulae. Removal of several small nodular lymph nodes. Extirpation of the gland with protection and exposure of the lingual nerve and ligation of the excretory duct. Complete resection of the cervical plexus branches, the accessorius nerve is also infiltrated. Separation of the internal jugular vein and the cranial sternocleidomastoid muscle. Now dissection of the carotid artery walled around the MCC at a good 180°. Further dissection reveals a clear infiltration of the vagus nerve. This is therefore resected. The hypoglossal nerve can be separated from the mass, here no infiltration. There is now an infiltration of the external carotid artery up to just before the bulb. The internal carotid artery is free. Separation of the external carotid artery close to the bulb and removal of a marginal sample. This is shown to be tumor-free in the frozen section diagnosis. Therefore, in sano resection of the carotid artery with an overall extensive surrounding wall and removal of the mass in toto which, however, is clearly inflammatory. Intraoperative drainage of serous fluid in the sense of extensive necrosis, overall vulnerable conditions. Subsequent right-sided release of the hemilarynx. Exposure of the thyroid cartilage....... Release of the right-sided piriform sinus. The left-sided resection of the hyoid was already performed during the metastasis resection. Now removal of the residual hyoid. Entering enorally at the level of the vallecula. Successive widening of the pharyngotomy sparingly along the right aryepiglottic fold. Now a good overview of the tumor. Incision of the tumor, which has clearly quieter mucosal extensions in the periphery with a safety margin of approx. 1.5 cm. Resection to just before the middle of the posterior hypopharyngeal wall. Deposition at the esophageal entrance. No more suspicious conditions here. The tumor is now completely covered with marginal samples in the mucosal area, the entire base is radically removed in the course of the neck dissection. The frozen section diagnosis now shows the invasive carcinoma R0 resected, circumscribed Cis in the area of the posterior hypopharyngeal wall. A resection is therefore performed here and a final marginal specimen removed, so that the overall situation is R0. Now to the harvesting of the antero-lateral thigh graft. After identification of the landmarks, doppler sonographic identification of the main perforator and 2 secondary perforators. Configuration of the graft to cover the pharyngeal defect due to the extensive hypopharyngeal resection in this case, as well as a skin defect measuring approx. 13 x 7 cm. A graft measuring a total of 27 x 8 cm was removed as a two-incision flap. Medial incision, separation of the extensive fat layer. Identification of the rectus femoris muscle. Subfascial release and exposure of the regularly configured pedicle vessel. Widening of the incision. Identification of the main perforator and two secondary perforators. Dissection of the perforators with circumscribed musculocutaneous course. Isolation on the perforators. Removal of the fascia lata to protect the perforators, otherwise it is left in place. Complete cutting of the graft. Isolation on the vascular pedicle and placement of the excellent vital graft after thinning out the lateral ends, paying careful attention to the vascular fat layer. Finally, vital graft and placement of the pedicle vessel. Subsequent insertion of 10 redon drains and careful multi-layer strong wound closure. <CLINICIAN_NAME> Neck dissection on the right: visualization of the sternocleidomastoid muscle. Exposure of the accessorius nerve, the submandibular gland and the digastric muscle. Then release of the neck preparation IIa to Va while sparing the plexus branches; the internal jugular vein and the cervical vascular sheath were previously exposed. The superior thyroid, facial and lingual arteries were preserved, as was the facial vein. Insertion of the transplant. First, the graft is sutured into the hypopharynx with the smaller skin island. To do this, start at the base of the tongue and successively suture in the entire graft portion intended for the pharynx. This is successful without any problems. Then reposition and advance the microscope and dissect the arterial vessels using <CLINICIAN_NAME>. The connective tissue is removed from the superior thyroid artery and the facial artery. Ultimately, there is very good flow in the superior thyroid artery. This is flushed with xylocaine by <CLINICIAN_NAME> and temporarily clamped. The vascular anastomosis is then performed by <CLINICIAN_NAME>. First suture the artery, this is successful without any problems. Dissection of the veins, the graft veins are extremely small and have many valves. It is therefore difficult to perform the venous anastomosis using a coupler. Finally, it is successful and the graft shows very good perfusion and also very good reperfusion. Then insertion of a Redon drain on the right side and a flap on the left side and fitting the second skin island of the graft first into the tracheostoma, then into the large skin defect on the neck.