Induction of anesthesia by the anesthesia colleagues. Entry with the Kleinsasser tube and inspection of the pharynx and larynx area. In the pharynx, an extensive exophytic mass can be seen in the area of the oropharynx, in the area of the tonsil lobe, infiltrating the anterior and posterior palatal arch and parts of the soft palate. The other pharyngeal areas and the larynx are unremarkable. Sterile washing and draping. Start with neck dissection on the right and left side in parallel. Right side, start with <CLINICIAN_NAME>. Skin incision so that the large cystic metastasis is cut around. A large area of skin must also be resected. Exposure of the sternocleidomastoid muscle in the caudal region. Exposure of the omohyoid muscle and exposure of the capsule of the mass. Dissection of the lower part of the internal jugular vein. Then take over by <CLINICIAN_NAME> and further release of the mass. The mass must be pushed away from the carotid artery. This is achieved without any problems in the area of the common carotid artery. In the bulb area, it can be seen that the external carotid artery is infiltrated by the tumor. The internal jugular vein is then ligated and the mass removed, taking with it the sternocleidomastoid muscle with which the mass has grown together. The hypoglossal nerve is also infiltrated and must be severed as well as the accessorius nerve. The plexus branches of the cervical plexus can be preserved. The vagus nerve can also be preserved. Ultimately, the entire neck preparation with the metastasis is removed en bloc. Only the common carotid artery and internal carotid artery as well as the vagus nerve and the border cord remain. At the same time, perform the neck dissection on the left side through <CLINICIAN_NAME> and <CLINICIAN_NAME>. Neck dissection on the left: Skin incision, transection of the cutaneous and subcutaneous tissue and the platysma. Subplatysmal dissection and elevation of the apron flap. Suturing of the apron flap. Exposure of the anterior border of the sternocleidomastoid muscle and dissection along the muscle in depth until the cervical plexus is exposed. Identification of the omohyoid muscle and dissection along the muscle to the hyoid bone. Identification of the accessorius nerve and the digastric muscle. Dissection medially to the hyoid bone. Release of the submandibular gland, which is left in place during dissection. Identification of the hypoglossal nerve. This can be safely spared. Dissection along the vein from caudal to cranial and detachment of the neck preparation. Sending in levels II, III, IV and V in individual preparations. Irrigation with hydrogen and Ringer and completion of the neck dissection on the left side without complications. Insertion of the tonsil plug and inspection of the tumor region. Incision of the tumor region with a safety margin of at least 1 cm in the oropharynx using the electric needle. Dissection with the needle as well as with scissors and bipolar forceps. The preparation is obtained en bloc and is placed on cork for frozen section. In the frozen section, all margins and also basal R0. The tumor resection creates a defect towards the neck. The tumor itself had no contact with the large metastasis and was still separated from it by a thin layer of tissue. Now measurement of the defect and lifting of the radialis graft from the left forearm by <CLINICIAN_NAME>. Lifting the radialis graft: Marking the graft on the distal forearm on the left side. S-shaped skin incision and proximal forearm. Exposure of the confluence and dissection of a superficial vein (cephalic vein) up to the radial flap edge. Incision along the marked skin incision down to the forearm fascia. Incision of the forearm fascia and subfascial preparation of the radialis graft. Care is taken to protect the external ramus of the radial nerve, particularly at the radial end. The ulnar artery can also be safely spared. Dissection of the distal section of the radial artery and ligation of the radial artery after prior control by clamping with a vascular clip. A good perfusion signal can be measured on the index finger during clamping. Then preparation of the radial artery graft from the depth under constant bipolar coagulation and placement of vessel clips on the perforator vessels. Dissection up to the crook of the elbow, reliable identification of the brachial artery, the ulnar artery and the interosseous artery. Separation of the radial artery after the exit of the interosseous artery. Separation of the veins and irrigation of the graft with heparin. Lift the split skin from the right thigh using <CLINICIAN_NAME> and <CLINICIAN_NAME>. Insertion of the graft from transcervical and transoral through <CLINICIAN_NAME>. Creation of the arterial and venous anastomosis. Arterial to the superior thyroid artery, venous to the facial vein and a second vein. The anastomosis is located on the left side. The stalk was guided over the larynx to the left. Then skin suture in the area of the left side of the neck and a second graft must be lifted to close the right side of the neck. A pectoralis major graft was harvested from the right side for this purpose. To do this, cut around a skin island 8 x 4 cm medial to the nipple. Then dissect down to the thoracic wall. Lifting of the petoral muscle from the thoracic wall. Detachment of the attachment of the pecotralis muscle from the sternum and humerus. The pedicle is clearly identified. The graft is pulled through a tunnel representing the theoretical deltopectoral flap. The deltopectoral flap was not lifted off, but only tunneled under medially. Dissection of a skin flap in the neck area, which is folded back. Fitting of the pectoralis major graft. Adjustment of the folded back neck skin in the sense of a plastic reconstruction. Beforehand, insertion of a Redon drain and completion of the procedure without complications. After the tumor resection, a tracheotomy was performed between the second and third tracheal cartilage in the usual manner. Insertion of a tracheal cannula. Suturing of the tracheostomy tube. Continue antibiotics for at least 24 hours. Flap checks in the usual manner. Presentation at the tumor conference after receipt of the histology. X-ray pelvic swallow after 14 days.