Carrying out the team time out and consultation with the anesthesia colleagues. Induction of intubation anesthesia by colleagues. Sterile wiping of the patient and start of the operation with the tracheotomy. Skin incision approx. 3 cm along just below the cricoid cartilage. Separation of the skin, the subcutis and the platysma. Dissection of the straight infrahyoid muscles. Push the muscles to the side and expose the thyroid isthmus. Undermining of the thyroid isthmus with a clamp and transection of the thyroid isthmus after extensive bipolar coagulation. Incision of the trachea between the 2nd and 3rd tracheal cartilage. Creation of a visor tracheotomy in the usual manner. Re-intubation with an 8-gauge laryngectomy tube. Cover and wipe the patient again and start neck dissection on the right side. Creation of an apron flap. Separation of the cutaneous and subcutaneous tissue and platysma. Subplatysmal dissection cranially until the submandibular gland is exposed. Release of the gland. Exposure of the anterior border of the sternocleidomastoid muscle. Exposure of the omohyoid muscle and dissection cranially to the hyoid bone. Exposure of the posterior venter of the digastric muscle and exposure up to the hyoid bone. Division of the neck preparation into a medial and a lateral compartment by free preparation of the internal jugular vein. The external jugular vein and the auricular nerve can be spared. Exposure of the accessorius nerve. This can also be spared. Removal of the neck preparation (region II to V) from the depths with constant coagulation of minor bleeding. Irrigation with hydrogen and Ringer and completion of the neck dissection without complications. Therefore, creation of an apron flap and start with the neck dissection on the left side. Exposure of the sternocleidomastoid muscle, the submandibular gland, the omohyoid muscle and the digastric muscle. Exposure of the cervical vascular sheath. Visualization of the jugular vein, visualization of the external jugular vein, visualization of the facial vein. Removal of the neck preparation II a to V a while sparing the plexus branches. Removal of the submandibular gland and transection of the omoyhoid muscle. This takes the tumor transorally. The tumor can be dislocated cervically and resected from the transcervical side. It can be completely removed. Take margin samples from all around the specimen so that the tumor specimen can be covered circularly with margin samples. The margin samples are taken from the specimen in frozen section R0. Also in depth. Measurement of the defect. 15 x 6 x 8 cm. Exposure and preparation of the neck vessels. The facial vein and the external jugular vein are dissected as venous connections. The arterial connection is the facial artery. The lingual artery was also removed during tumor resection, as was the lingual nerve. Lifting of the split skin by <CLINICIAN_NAME> from the right thigh. This is successful without any problems. Treatment of the forearm using <CLINICIAN_NAME> and <CLINICIAN_NAME>. Exposed tendons are sutured over with muscle. The defect is covered with split skin and treated in the usual way with sewn-on swabs and compresses. Application of a dorsal forearm splint. Please continue antibiotics postoperatively for at least 24 hours. Regular flap checks. First forearm dressing change on the 7th postoperative day. Earlier of course if symptoms occur. Demonstration to the surgeon. Tumor resection by <CLINICIAN_NAME>. Sterile washing and draping. Insertion of the McIvor mouth blocker and start of tumor resection. The tumor extends from the soft palate parauvularly over the alveolar ridge and the tonsillar lobe caudally, it spreads to the edge and base of the tongue on the left in the caudal region. Start with tumor resection in the soft palate area and continue the resection caudally, taking part of the alveolar ridge with it. However, the tumor itself can be easily moved away from the bone. To be on the safe side, the bone is ground down again. Dissection up to the base of the tongue. The overview then makes it no longer possible to resect the tumor further from the transoral side. Elevation of the radial lobe from the left forearm: After appropriate measurement of the size and three-dimensional configuration of the defect after ensuring R0 resection, the flap is marked accordingly on the forearm. Incision of the flap first from the ulnar and lifting subfascially. The incision is then extended into the crook of the elbow. Exposure of the superficial venous system and the connection to the deep venous system. Subsequently incision of the flap also from radial and lifting subfascial. Exposure of the radial artery. This is first clamped off. Then expose the pedicle and the connection to the superficial venous system. Further lifting of the flap subfascially from the radial side. Exposure and preservation of the lateral antebrachial cutaneous nerve as far as possible. The pedicle must be isolated under the brachioradialis muscle. The radial artery should then be removed. Saturation always in the normal range after clamping. The radial artery is ligated caudally and distally. Lift the radial artery flap along the pedicle. Outgoing small vessels are bipolarly coagulated or clipped. A total of two outlets from the cephalic vein can be visualized in the antecubital region. A smaller vein branches off from one of the outlets. A common confluence above the radial artery can also be visualized and preserved. The interosseous artery is clamped and later severed. The radial artery is detached and closed using 6.0 Vascufil in the area of the brachialis stump. Veins are removed and ligated. Flap is irrigated with heparin. The forearm is primarily closed cranially. Caudal closure using a split-thickness skin graft taken from the right thigh. This succeeds completely and without tension. Ball swabs are sutured to some areas. Octenilin gel is then applied. Application of Mepilex, which is fixed with sutures. Subsequent application of cloud swabs and wrapping of these with a absorbent cotton bandage. Then fitting of a Cramer splint, which is fixed to the forearm in the functional position using an elastic bandage. Subsequent positioning of the arm. The flap is then sutured into the defect. First suture the flap transorally or transcervically. This is done with 3.0 Vicryl single button sutures, partly with the sutures in place. Complete tension-free closure of the defect is achieved. This includes parts of the anterior and posterior palatal arch, the pharyngeal wall, the vallecula and the base of the tongue as well as the posterior parts of the floor of the mouth. The left pedicle is drained into the left side of the neck. The second facial artery, which has been dissected, is used as the connecting vessel. First, after conditioning the two arteries, anastomosis of the facial artery with the radial artery using 8.0 Ethilon single-button sutures. After opening the clamps, good arterial flow and good venous return. Subsequent conditioning of the external jugular vein and the facial vein for the venous connection. A portion of the cephalic vein is anastomosed using a 3.5 mm coupler after conditioning of the veins. Good venous flow after opening the clamp. Positive smear phenomenon. The other part of the cephalic vein is anastomosed with the facial vein using a 2.5 mm coupler at an outlet. Here too, after opening the clamp, good venous flow, positive smear phenomenon. The confluence is clipped, as are other outlets from the facial vein. Subsequent careful hemostasis. Irrigation of the sides of the neck on both sides. Closure of the skin with insertion of a Redon drain on the right and two flaps on the left and epithelialization of the tracheostoma. Insertion of an 8 mm tracheal cannula, which is fixed with sutures. In the area of the skin above the vascular anastomosis, a suture marker is placed for Doppler control. Hydrogel dressing is applied to the thigh area. Thoracic inspection shows good circulation in the area of the flap. The procedure is completed without complications. Patient transferred to the intensive care unit on mechanical ventilation. Please continue antibiotics, which were started intraoperatively, for a total of one week postoperatively. Feeding via the PEG tube for approx. 10 days, followed by gruel and, if necessary, a diet. Continue intraoperative therapy with heparin perfusor for 5 days at 500 units per hour. Check the flap clinically and by Doppler according to the scheme for 5 days. Overall cT4a cN2c oropharyngeal carcinoma on the right. Presentation after receiving the final histology in the interdisciplinary tumor conference.