First, a pharyngoscopy is performed to determine the exact extent of the tumor: An exophytic mass is found on the left oropharyngeal side wall. Tumor growth begins at the posterior palatal arch with transition to the lateral pharyngeal wall and to approximately one third of the posterior pharyngeal wall. The tonsil and the anterior palatal arch are not infiltrated macroscopically and palpatorily. Growth over the posterior palatal arch up to the vicinity of the parauvular mucosal triangle. Overall moderate palpatory displacement. After positioning the patient, first transoral tumor resection: To obtain an overview and safe resection, enter the anterior palatal arch, taking the tonsil with you. Entering the anterior palatal arch. Release of the tonsil using the dissection technique. Behind the tonsil without direct contact, but according to ....................... the tumorous mass is now encountered. First cut around the mass on all sides with an electric knife. Resection up to the middle of the posterior pharyngeal wall. Problem-free loosening and resection of the tumor to the caudal and medial border. Complete removal of the posterior palatal arch. After loosening the edges in depth, careful dissection. However, a good displacement layer is now visible here, so that the tumor can be completely resected transorally macroscopically in sano. Circumscribed exposed fatty tissue from the neck, but no direct contact with the carotid artery as described in the CT scan. The tumor is now sent macroscopically in toto for frozen section diagnostics. If the resection in the area of the parauvular triangle on the posterior palatal arch is macroscopically scarce, a complete resection is performed here as well as a covering final margin sample, which is also sent for frozen section diagnostics. The tumor is now diagnosed in sano on all sides; only in the area of the caudal pharyngeal margin is there a clear alteration with questionable CIS. A new resection is therefore performed here, which is diagnosed as completely tumor-free in the frozen section diagnostics. Also basal free conditions. The deep wound bed is also resected later via pharyngotomy and placement of the vascular pedicle. After careful hemostasis, the neck is dissected on the left side: after injection of xylocaine with added adrenaline, the skin incision on the anterior edge of the sternocleidomastoid muscle is modified in a curved fashion. Cut through the skin and subcutaneous tissue. Exposure and transection of the platysma. Creation of a platysma flap. Exposure and careful preservation of the external jugular vein, which is very pronounced. Exposure of the sternocleidomastoid muscle, the omohyoid muscle, the submandibular gland and the digastric muscle. Release of the anterior neck preparation with careful protection of the superior thyroid artery and vein, the hypoglossal nerve and the cervical vein. Free preparation of the internal jugular vein. The vein shows clear wall changes, palpation with residual flow, no evidence of inflammatory changes, therefore the vein is left intact. Clear collateral formation with strong external jugular vein and anterior jugular vein. Exposure of the accessorius nerve. Clearing of the accessorius triangle and level V with careful protection of the cervical plexus branches. Overall macroscopically no suspicious nodes. Irrigation of the wound. Now turn to pharyngotomy. Resection of the digastric muscle, exposure of the stylohyoid. Exposure of the cervical vascular sheath and the external carotid artery. Preservation of the superior thyroid artery, the lingual artery, the facial artery and the occipital artery. Blunt perforation of the pharynx in the direction of the resection area. Widen the pharyngotomy until an approximately 3 ˝ finger-wide shaft is created. Basal co-resection of the wound bed. Neck dissection of the right side and radialis graft harvesting from the lower left side are now performed in parallel. Neck dissection on the right: In principle the same procedure as on the opposite side. Skin incision on the front edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Exposure and transection of the platysma. Creation of a platysma flap. Exposure and preservation of the external jugular vein. Exposure of the sternocleidomastoid muscle, the omohyoid muscle, the submandibular gland and the digastric muscle. Clearing out the anterior neck preparation while carefully protecting the superior thyroid artery and the hypoglossal nerve. Exposure and protection of the accessorius nerve. Clearing out the accessorius triangle while carefully protecting the nerve. Completion of level V with careful protection of the cervical plexus branches. Final wound inspection. Wound irrigation. In dry wound conditions, without macroscopically suspicious nodes, insertion of a 10 Redon drain and careful, two-layer wound closure. Removal of the radialis graft from the left forearm: After marking a graft measuring 13 x 6 cm in total, using a skin monitor, the graft is cut into a bloodless area. Initially radial exposure and removal of the cephalic vein. Exposure and preservation of the superficial radial nerve ramus, which can remain completely intact. Expose the distal vascular pedicle. Dissection of the vascular pedicle. Strictly subfascial release of the graft. The ulnar artery lies deep and is not exposed. Strictly subfascial dissection of the graft with careful clipping of the outgoing muscle branches. Removal of the monitor bed. In the antecubital fossa it can now be seen that the cephalic vein remains relatively slender and does not form a visible bridge to the radial vein area. However, the radial veins unite to form a strong, common vessel, hence clipping of the cephalic vein, isolation also artery and vein. After reopening of the tourniquet, regular hand perfusion and excellent graft perfusion. Minutious hemostasis. Removal of the graft after regular blood flow. Subsequently, after wound inspection, careful, two-layered wound closure and insertion of the full-thickness skin graft lifted from the right groin. A vacuum sealing pump is then applied, the Kramer splint is placed in the functional position and the arm is repositioned. Full-thickness skin harvesting from the groin: For this purpose, cutting around an oval piece of skin measuring 15 x just under 6 cm, strictly cutaneous elevation, subcutaneous mobilization. Hemostasis and wound inspection. Placement of a 10 Redon drain and strong, two-layer wound closure under moderate tension. Now insertion of the graft combined transorally and transcervically. This is now considerably more difficult due to significant swelling in the throat and tongue area. Good fit, but extremely laborious insertion due to the local conditions and tight spaces. Finally, adequate suture intact on all sides. Positioning of the vascular pedicle and the cervical skin monitor. In the meantime, the tracheotomy was also performed due to the swelling conditions described: For this, with very deep lying cricoid cartilage, skin incision at the level of the cricoid cartilage. Cut through. Cut through the skin and subcutaneous tissue. Exposure and transection of the very strong anterior jugular vein. Ligation of the infrahyoid muscles that represent the veins. Dissection of the musculature. Exposure of the cricoid cartilage and the thyroid isthmus, which is coagulated if very thin. Very deep trachea, therefore insertion between the 1st and 2nd tracheal ring. Creation of a broad-based pedunculated Björk flap. Difficult incision with a low-lying trachea, but finally a wide tracheotomy and problem-free intubation onto an 8-gauge low-cuff cannula, which is suture-fixed. This is followed by cervical vascular preparation. This involves conditioning the flap vessels and the strong facial artery, which corresponds most closely to the strong radial artery. Carefully adapt the vascular suture with 8.0 Ethilon. Subsequently, regular flow conditions with immediate venous return and excellent graft perfusion, therefore now conditioning of the external jugular vein. If the flow is good, measure a size 3.5 coupler and perform the venous anastomosis with the coupler without any problems. Subsequently, regular blood flow with renewed excellent vitality of the graft and the skin monitor. Positioning of the skin monitor and insertion and careful, two-layer wound closure after insertion of a 10 Redon drain. Vital graft conditions at the end of the operation. Transfer of the patient intubated to the intensive care unit. Conclusion: Intraoperative R0-resected cT2 cN0 oropharyngeal carcinoma on the left. Laborious but sufficient reconstruction using a radialis graft. Due to the laborious intake conditions, the evaluation of the dietary reconstruction .............. Swallowing function should only be evaluated from the 9th to 10th postoperative day. Cannula supply, depending on swallowing function. Please strictly avoid cervical pressure dressings and exercise extreme caution when manipulating a venous anastomosis that is directly subcutaneous.