Pharyngoscopy and laryngoscopy again: confirmation of the extent of the tumor. Then repositioning for surgery: covering of all relevant surgical areas, injection of a total of 10 ml Ultracaine 1% with adrenaline into each side of the neck. Start with transoral tumor resection: insertion of Mc Ivor spatula. Exposure of the tumor. Cut around the tumor with a safety margin of approx. 2 cm along the mucosa. Resection includes anterior palatal arch up to the uvula. Posterior palatal arch can remain. A layer in the pharyngeal region can be dissected without showing tumor infiltration. Resection also includes the glossotonsillar groove along the alveolar ridge and parts of the base of the tongue and extends to the entrance of the hypopharynx. Tumor specimen is removed, thread-marked and sent for frozen section. Mucosal margins free in the frozen section, basal superior and inferior also free, basal medial near the large vessels forming a tumor margin. Therefore, definitive indication for resection of the entire pharyngeal wall and flap coverage. Neck dissection on the right and completion of the tumor resection from transcervical: skin incision in typical manner. Exposure of the sternocleidomastoid anterior wall. Exposure of the omohyoid muscle and digastric muscle. Exposure of the internal jugular vein, the facial nerve with several outlets. Depiction of the internal carotid artery, external carotid artery and several branches. Exposure of the hypoglossal nerve, vagus nerve and accessorius nerve. Subsequent clearing of levels II to V while preserving the branches of the cervical plexus. Some enlarged lymph nodes cranially in levels II to III, macroscopically not clearly suspicious of malignancy. Then completion of the tumor resection from transcervical. The external and internal carotid arteries as well as the hypoglossal nerve and jugular vein are all marked using vessel loops and dissected from the pharyngeal wall. Subsequently, resection of the entire pharyngeal wall from the upper tonsil pole to the beginning of the base of the tongue under external and internal control. The pharynx was also suture-marked there. In the frozen section, there was no tumor here laterally towards the vessels. Thus final R0 resection. Neck dissection is then performed on the left: It is started from <CLINICIAN_NAME> and <CLINICIAN_NAME> and then completed. As on the opposite side, this is followed by visualization of all structures and level II-IV clearing. No significant enlarged lymph nodes here either. Subsequent tracheostoma placement: small Kocher collar incision here. Dissection through the subcutaneous tissue to the infrahyoid musculature, which is split. Subsequent exposure of the thyroid isthmus. This is passed underneath, clamped off, severed and supplied with puncture ligatures. The anterior surface of the trachea is then exposed. Creation of a broadly pedicled, modified Björk flap. This is then epithelialized in the typical manner to make it virtually tension-free. Then reintubation. Insertion of an 8 mm tracheostomy tube. Tracheotomy was performed by <CLINICIAN_NAME>. Flap then removed from the left forearm: After measuring the size approx. 10 x 7 cm, mark the flap in the corresponding size dimension on the left forearm. Skin incision from the crook of the elbow curved to the flap borders, then ulnar. Lift the flap subfascially from the ulnar side. Outgoing vessels are ligated or bipolized or clipped. Subsequent visualization of the superficial vein system. Visualization of a connection between the superficial and deep venous system. Exposure of the pedicle under the brachioradialis muscle. Then recutting of the flap from the ulnar side. Exposure and preservation of the lateral antebrachial cutaneous nerve. Distal exposure of the radial artery, which is first clamped for approx. 10-15 minutes. Always 100% saturation here. The radial artery is then removed. This is treated with 4-0 Prolene sutures proximally and distally using a bypass ligature. Securing suture on the skin area of the flap. The flap is then lifted from caudal to cranial, taking the pedicle with it. Outgoing vessels are ligated or clipped. First clamp the interosseous artery in the elbow area. After consistently good saturation of almost 100 %, clipping or puncture ligation of this. Two outgoing cephalic veins can be seen in the elbow area. The confluence in the area of the radial artery is relatively thin and is also lifted. The flap is then removed. Ligature of the veins, treatment of the edges of the apposition in the area of the brachial artery using 6-0 Vascufil sutures. Flushing of the flap with heparin solution. Split skin is removed from the thigh. This is successively incorporated into the defect on the left forearm. Skin is closed cranially in a typical layered fashion. Subsequent application of octenidine and Mepilex as well as small clouds. Fixation with absorbent cotton. Then fitting of a Cramer splint and fixation of the hand using an elastic bandage. Subsequent application of the hand. Saturation always at 97-100 %, no special features. Then suturing of the radial flap into the defect: This is successively sutured into the defect, which extends from the palatal arch to the base of the tongue or hypopharyngeal entrance. Suturing using 3-0 Vicryl single button sutures, partly under a template. Suturing is complete and tension-free. Then anastomosis of the vessels of the flap. Selection of 2 outlets from the facial vein area. The facial artery is selected for the arterial anastomosis. The facial artery is sutured to the radial artery after conditioning with 8-0 Ethilon single-button sutures. After opening the clamps, good arterial pulse, good venous return, no special features. Subsequent anastomosis of an outlet of the cephalic vein with an outlet from the facial vein using a 3-0 coupler. Again, good venous return after opening the clamp. Positive smear phenomenon. Subsequently, a 2nd outlet from the facial vein is anastomosed with the 2nd outlet from the cephalic vein with a 3.5 mm coupler. No special features here either. Smear phenomenon more positive. Good reflux after opening the clamp. Another small vein is clipped in the area of the flap pedicle. Subsequently, careful positioning of the flap pedicle to prevent kinking. Careful hemostasis is then performed again. Irrigation of the wound area, wound closure in layers on the right side with insertion of 2 flaps. A skin suture is placed in the area of the flap pedicle for Doppler control. On the left side, the skin is closed in the typical layered fashion with the insertion of a Redon drain. The cannula was suture-fixed after insertion. Check of the endaural flap, this is inconspicuously regular. A hydrogel dressing was applied to the thigh area. The procedure was completed without complications. The patient is transferred to the intensive care unit postoperatively on mechanical ventilation. Please continue antibiotic treatment, which was started intraoperatively with Unacid 3 g, for a total of 1 week. Nutrition for 10 days via inserted PEG or already inserted PEG tube. Then swallow gruel and if necessary build up the diet. Flap control typically for 5 days by means of Doppler control, but above all clinically transorally. Please run heparin perfusor 500 E/h for 5 days. Overall cT2-3 tonsillar carcinoma, which infiltrated the wall deeply and therefore required flap coverage. Waiting for histology in the area of the cervical lymph nodes, then presentation at the tumor conference.