First, pharyngo- and laryngoscopy again: The exophytic tumor is seen with deep crater formation in the area of the palatal arch up to the uvula, growth on the posterior side of the palatal arch and towards the nasopharynx, growth deep into the soft tissues towards the pharyngeal wall and mandible, growth up to the base of the tongue via the lateral oropharyngeal wall and into the hypopharynx. Larynx itself not involved by macroscopically visible tumor. Confirmation of the indication for surgery. Now PEG placement, neck dissection and tracheostoma placement. These surgical steps are dictated by <CLINICIAN_NAME>. First placement of a PEG tube. This is carried out without complications using the thread pull-through method with adequate diaphanoscopy in the typical manner. A neck dissection is then performed on the right side. Creation of a skin incision along the anterior edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Dissection of the platysma. Exposure of the anterior border of the sternocleidomastoid muscle. Exposure in the depth of the nervus accessorius, the omohyoid muscle and the posterior venter of the digaster muscle. Dissection along the cervical vascular sheath. Exposure and sparing of the vagus nerve and the common carotid artery. Removal of the neck specimen posteriorly while sparing the above-mentioned structures. Protection of the deep plexus branches. Hemostasis using bipolar coagulation. Subsequent removal of the anterior neck preparation. Hemostasis using bipolar coagulation. Wound irrigation using hydrogen peroxide and Ringer's solution. Placement of a 10 Redon drain. Two-layer wound closure. Now repositioning of the patient to perform a neck dissection on the left side. Creation of a skin incision along the anterior edge of the sternocleidomastoid muscle. Cut through the skin, the subcutaneous tissue and the platysma. Exposure and dissection along the anterior border of the sternocleidomastoid muscle. Exposure of the accessorius nerve, the posterior venter of the digaster muscle, the omohyoid muscle and the capsule of the submandibular gland, which is removed in the preparation. Exposure and protection of the cervical vascular sheath. Removal of the posterior neck specimen while preserving the above-mentioned structures and the plexus branches. Removal of the anterior neck specimen. Hemostasis using bipolar coagulation. Placement of a 10 Redon drain and two-layer wound closure and completion of the neck dissection on the left side. A tracheotomy is then performed in the typical manner. Creation of a skin incision directly below the level of the cricoid cartilage, approx. 3 cm long. Cut through the subcutaneous tissue. Exposure of the prelaryngeal musculature. Exposure of the thyroid isthmus. Undermining of the thyroid isthmus using Pean clamps. Dissection of the thyroid isthmus and ligation of both thyroid stumps. Exposure of the anterior wall of the trachea. Creation of a tracheal incision between the 2nd and 3rd tracheal cartilage clasp using a scalpel. Creation of a Björk flap in the typical manner and epithelization of the tracheostoma. Reintubation to a size 8 Rügheim tracheostomy tube. Completion of the procedure without complications. Subsequent combined transcervical, transoral tumor resection: First, all vessels, internal jugular vein, internal and external carotid artery and all cranial nerves including vagus nerve, hypoglossal nerve and glossopharyngeal nerve are severed from the pharyngeal wall to the base of the skull and marked with vessel loops. Detachment of the tumor from the spinal column, which is successful with a blunt approach, no infiltrations visible here. Then cut around the tumor from the transoral side with a safety margin of at least 1.5 to 2 cm on all sides. The entire palatal arch falls down to the uvula, leaving the remaining palatal arch on the left. The soft palate is resected, as well as the posterior side up to the nasopharynx, taking the tube partially with it. Push off the soft tissue under control from the outside to just in front of the lower jaw. Co-resection of the pharyngeal wall and the pterygoid muscles. Detachment of the tumor also from the transoral and cranial side of the spinal column. Large parts of the posterior pharyngeal wall are also resected. The tumor is resected from the transcervical side in the tongue base area, whereby almost half of the tongue base area with vallecula and parts of the lateral epiglottis as well as parts of the hyoid bone are also resected. The resection extends into the piriform sinus and includes parts of the lateral laryngeal area including parts of the thyroid cartilage from the mucosa to the arytenoid fold. However, arytenoid cartilage is preserved. Vallecula parts are resected up to the middle. The entire specimen is removed and marked using several sutures. In addition, marginal samples are taken caudally from the posterior pharyngeal wall, from the piriform sinus up to the arytenoid fold, basally from the base of the tongue with soft tissue and mucosa, a marginal sample basally caudally, a marginal sample from the lateral epiglottis and a marginal sample from the posterior wall of the palatine arch at the transition to the nasopharynx. The specimen as a whole is in situ, as are the marginal samples, i.e. R0 situation. The defect includes the piriform sinus, lateral oropharyngeal side wall, palatal arch, posterior pharyngeal wall, base of tongue and vallecula. Defect is measured three-dimensionally. Irrigation of the wound area with H2O2 and Ringer's solution and careful hemostasis. The dimensions and size of the defect are recorded on the right forearm, flap size max. 16 cm in length and just under 10 cm in width. Now flap removal: first cut around the flap ulnarly subfascially. Extend the incision into the crook of the elbow. Subsequent exposure of the radial artery. This is initially clamped for 15 to 20 minutes. ........... Incision of the flap also from radial subfascial. Ramus cutaneus antebrachii is preserved as far as possible. The superficial venous system is exposed and also elevated. Exposure of the vascular pedicle under the brachioradialis muscle. Exposure of the connection between the superficial and deep venous system. Now expose the radial artery. This is relatively deep. Pulse oximeter always at 100% after clamping, no special features or abnormalities. 100% saturation even after clamping until the end of the operation. Successive lifting of the flap subfascially. Outgoing smaller vessels are clipped or bipolar coagulated. Lift the flap with the superficial vein system and pedicle up to the antecubital fossa. Two branches from the cephalic vein can be dissected here as connecting veins. The radial artery can also be dissected up to just before the brachial artery entrance. Also a venous confluence. The interosseous artery was cut and ligated. The flap was then removed. The edge of the radial antebrachial artery is treated with Prolene 4-0 puncture ligatures. The veins are ligated. Flap vessels are flushed with heparin. A piece of full-thickness skin of the appropriate size is removed from the groin. This is conditioned and incorporated into the forearm defect. The cranial defect is closed in layers. A hydrogel-Mepilex dressing and a swab dressing are applied, wrapping with sterile absorbent cotton, application of a Kramer splint and wrapping of the arm with an elastic bandage, application of the arm. Blood circulation always ensured. Now insert the flap into the defect. Gradual incorporation of the flap. The palatal arch area can be effectively replaced, as can all anatomical regions. Only in the cranial area of the posterior wall is complete defect coverage not possible, here not only a double but a triple fold would have to be made, which does not appear to be technically possible. To secure the nasopharyngeal passage, a gastric tube is inserted during flap insertion and the position is also successfully checked. Suturing is performed with 3-0 Vicryl single button sutures, partly from the transoral and partly from the transcervical side, partly also after the insertion of sutures. The result is a tension-free and complete closure of the defect, whereby, as described, the most cranial parts of the posterior pharyngeal wall are not covered. There is still muscle and fascia on the spine. The vessels on the flap and in the neck area are then conditioned. The superior thyroid artery is selected, which is connected to the radial artery in 8-0 single button sutures. After opening the clamp, good arterial flow, good venous return. Subsequent conditioning of the veins. It can be seen that a vein can still be used at the internal jugular artery. However, it is also apparent that the internal jugular vein is partially thrombosed due to insufficient flow. Opening of the vein, thrombus can be expressed, after which flow is possible again. Due to the fact that there are no other veins left and the stalk cannot be passed through to the left side due to the shortness of the stalk relative to the required distance, the largest cephalic vein is now connected to the facial vein using a 3-0 coupler. Good flow after opening, also positive smear phenomenon. No further signs of thrombosis in the further course, so that here, with probably a lack of return flow from the cerebrum, the return flow from the flap appears to counteract further thrombosis. Other veins are clipped. Enoral flap control brings good conditions. Irrigation of the entire wound area. Careful hemostasis. Wound closure in layers with insertion of a Redon drain on both sides, guided on the right. Completion of the procedure without complications. Patient transferred to the intensive care unit for postoperative monitoring. Please continue heparin perfusor, which was started intraoperatively at 500 units per hour, for 5 days. Continue antibiotic treatment with Unacid, which was started preoperatively, for 1 week. Feeding via PEG for at least 10 days, then gruel and, if necessary, slow, careful build-up of diet. Flap control according to the scheme for 5 days by means of Doppler and clinical checks. Position of the anastomosis or stalk marked with suture. Overall multistage carcinoma cT4 cN2c. Postoperative radiochemotherapy certainly indicated. Please discuss the procedure in the interdisciplinary tumor conference.