First, pharyngoscopy and laryngoscopy again: The exophytic tumor is visible, which grows from the lower tonsil pole via the glossoalveolar or glossotonsillar region to the base of the tongue, via the lateral wall of the oropharynx to the posterior wall of the oropharynx. Therefore, surgical indication for resection with flap coverage. First, skin disinfection and sterile draping of all surgical areas, including the right forearm and thigh. First tracheostoma placement and PEG placement by <CLINICIAN_NAME>. After problem-free orotracheal intubation by the anesthesia colleagues, first tracheostomy in the typical manner: Marking of the landmarks and the well palpable cricoid cartilage level and prior local anesthetic infiltration with Ultracaine 2% with suprarenin addition caudal to the cricoid cartilage. Skin incision according to Kocher and separation of the skin and subcutaneous tissue. Dissection in layers and then exposure of the infrahyoid musculature. Ligation of a small median vein beforehand. Dissection on the cricoid cartilage and from here dissection caudally on the trachea without significant thyroid tissue, thus now a good view of the anterior surface of the trachea after previous transection of the linea alba. Then opening of the trachea between the 2nd and 3rd cartilage clasp and insertion of a visor tracheotomy and circular tension-free mucocutaneous anastomosis. Problem-free intubation onto an LE tube. Now PEG insertion: Pre-mirroring with the flexible endoscope while inspecting the irritation-free esophageal mucosa and air insufflation in the stomach. If diaphanoscopy is excellent, insertion of the PEG using the thread pull-through method in the typical manner. Perioperative administration of 3 g Unacid. On withdrawal of the endoscope, re-inspection of the lesion-free esophageal mucosa. Subsequent repositioning for neck dissection and tumor resection by <CLINICIAN_NAME>: Opening of the old scar and extension slightly submentally. Extension also caudally. Subsequent neck dissection on the right: exposure of the digastric muscle, omohyoid muscle, sternocleidomastoid muscle. Exposure of the internal carotid artery, external carotid artery, superior thyroid artery, facial artery and lingual artery. Exposure of the hypoglossal nerve, vagus nerve and accessorius nerve. Clearing of levels II to V, preserving the branches of the cervical plexus. Subsequent removal of the right submandibular gland in preparation for tumor resection. Also removal of level I b lymph nodes. The entire dissection was considerably more difficult due to scarring, in particular the veins and also the larger vessels were distorted cranially superior to the pharyngeal wall in the sense of severe scarring. Difficult removal of the scars. A facial vein with 2 outlets and a further outlet from the internal jugular vein can be dissected from the scar tissue. Subsequently, combined transoral, transcervical tumor resection: All large vessels and nerves are ligated using Wessel loops and pulled to the side. The tumor is then resected under internal and external control. Incision of the macroscopically visible tumor at a distance of 1.5 cm on all sides. The area of the posterior palatal arch, the entire tonsil lobe, the mucosa up to the alveolar ridge, parts of the base of the tongue, the lateral wall of the oropharynx and approx. 2 thirds of the posterior wall of the oropharynx are resected. Resection up to the border of the nasopharynx. The specimen is sent to the frozen section marked with a thread. Also marginal samples from basal, which includes hyoid bone and adjacent soft tissue. Marginal specimen from the vallecula to the caudal base of the tongue and marginal specimen from the posterior palatal arch to the upper posterior wall of the oropharynx adjacent to the nasopharynx. Marginal samples are thread-marked for frozen section. The frozen section still shows infiltrates in the area of the cranial margin of the posterior palatal arch and the cranial oropharyngeal wall. Here, another resection over several millimeters and another removal of a marginal sample, which extends from the border area at the alveolar ridge over the posterior palatal arch remnant to the posterior oropharyngeal wall. This is again sent to the frozen section. Carcinoma in situ infiltrates in the medial cranial area, i.e. in the oropharyngeal area extending to the nasopharynx. Therefore, another resection and subsequent removal of a marginal sample from the cranial oropharyngeal area or now already the nasopharyngeal mucosa area. No more higher-grade dysplasia or carcinoma infiltrates here. Thus a surgical R0 situation, although field carcinomatization cannot be completely ruled out. Typical skin incision and neck dissection on the left: This is performed in the same way as on the right side. Evacuation of levels II to V and preservation of the structures and branches of the cervical plexus. Ligation in the area of the inferior lymphatic vessels. Subsequent careful irrigation and hemostasis of all surgical areas. Measurement of the defect and the three-dimensional configuration. Defect length approx. 11 cm and width 8 to 9 cm. Recording on the forearm according to the orientation. Subsequent elevation of the forearm flap: First, recutting of the ulnar and superfascial preparation. Then extend cranially to the crook of the elbow. Exposure of the superficial venous system and the connection to the deep venous system. Subsequent radial incision. Exposure and preservation of the lateral antebrachial cutaneous nerve. As far as possible. Caudal exposure of the radial artery. After clamping and sufficient time with adequate saturation of the forearm, cut through. The artery is ligated with 4-0 Prolene stitches. Lift the flap along its deep pedicle, including the superficial pedicle. Outgoing vessels are clipped or bipolar coagulated. Two branches of the cephalic vein and a confluence can be visualized in the antecubital fossa. The interosseous artery is cut and clipped after clamping and good saturation. The cephalic vein, the confluence and the radial artery are then removed. The artery is closed with stitching sutures after removal. The veins are ligated. Irrigation of the flap. The flap is then inserted into the defect. Successive suturing using 3-0 Vicryl single button sutures. Tension-free closure is achieved, even with reconstruction of the posterior palatal arch. Difficult suturing cranially in the area of the nasopharynx. Subsequent vascular anastomoses. Conditioning of the radial artery and the superior thyroid artery. The superior thyroid artery must be incised slightly, followed by anastomosis with 8-0 Ethilon single-button sutures. After opening the clamp, good arterial flow, good venous return. One of the cephalic veins is anastomosed with an outlet from the prepared facial vein after appropriate conditioning with a 3-0 coupler. Here, too, good venous return after opening the clamps, positive smear phenomenon. The other outlet from the facial vein is anastomosed with the 2nd outlet of the cephalic vein. Here, too, the smear phenomenon is positive after opening the clamps, good venous flow after opening the clamps. The confluence is clipped. Subsequent preparation and fixation of the pedicle in a favorable position. Irrigation of the surgical site. Hemostasis. Wound closure in layers on the right and insertion of 2 flaps on the left with insertion of a Redon drain. Epithelialization of the tracheostoma is completed. Insertion of an 8 mm tracheostomy tube, which is fixed with sutures. Thoracic inspection shows flap well perfused. The forearm is primarily closed cranially, the defect is closed caudally using split skin taken laterally from the right thigh with a thickness of 0.8 mm. Here, after taking swabs and relief incisions, Mepilex is taken and loose compresses are applied and fixed with absorbent cotton. A Kramer splint is then fitted and secured with an elastic bandage. Positioning of the arm. Saturation of the hand is always above 95 to 100 %. Starch is applied to the thigh area and then Mepilex. The procedure is completed without complications. Patient goes to the intensive care unit ventilated. Please continue antibiotics, which were started intraoperatively with Unacid, for approx. 1 week. Feeding via the inserted PEG tube, which should be loosened after 24 hours, for approx. 10 days, followed by gruel swallowing and, if necessary, diet build-up. Check blood flow to the flap clinically or by Doppler. Overall cT4a oropharyngeal carcinoma recurrence. Please wait for lymph node status and then presentation at the interdisciplinary tumor conference.