First pharyngoscopy and laryngoscopy: The exophytic tumor is seen, which occupies the entire palatal arch and extends over the pharyngeal side wall to the base of the tongue, vallecula area and piriform sinus entrance. The tumor is first resected transorally: after reclination of the head, the Mc Ivor blade or retractor is inserted alternately. The tumor is resected on all sides with a safety margin of at least 1.5 cm to 2 cm. The entire palatal arch up to the tonsil on the right and the pharyngeal side wall including the parapharyngeal muscles are resected. Resection extends via the alvoelar ridge, which is exposed in the posterior part, to the posterior parts of the floor of the mouth and includes the base of the tongue, which is resected to about 30 %. This is followed by marginal samples from the palatal arch area, whereby the resection is carried out continuously from the upper to the lower mucosal border. Further marginal samples from the lateral alveolar ridge, from the base of the tongue and from the posterior area of the palatal arch and the transition to the upper oropharyngeal wall. In addition, a marginal sample from the soft tissues cranial as cranial basal. All marginal samples are healthy. Then repositioning for neck dissection and transcervical resection: First start with neck dissection on the left side: curved skin incision. Exposure of the sternocleidomastoid muscle anterior margin. Dissection of fat/lymph node preparation. Several larger lymph nodes palpable. These are laboriously dissected from the cervical vascular sheath. The facial vein is severed and cannot be preserved, likewise other veins around the lymph node conglomerate. Exposure of the omohyoid muscle, digastric muscle. Representation of the cervical vascular sheath, internal jugular vein, which can be preserved, internal and external carotid artery. Exposure of the vagus nerve and accessorius nerve as well as the hypoglossal nerve. All structures can be preserved. Removal of the lymph node conglomerate. Subsequent removal of the remains of the lateral neck preparation and preservation of the branches of the cervical plexus. Then removal of the remains of the medial neck preparation. Also removal of the submandibular gland and attached level I b lymph nodes. Careful preservation of the facial artery. This results in removal of the level I b to V lymph nodes. Neck dissection on the right side: This is carried out in the same way as on the left side, exposing and preserving the structures mentioned. Level II to IV evacuation is performed here, followed by careful hemostasis and irrigation on both sides. Then complete the tumor resection on the left side from the transcervical side: exposure of the external and internal carotid artery. Tumor resection is now completed. All parts of the wall are resected while sparing the large vessels. Caudally, the resection extends to the piriform sinus entrance, medially to the vallecula area. The epiglottis remains intact. This is followed by marginal samples of the pharyngeal wall medially caudally and in the caudal region. A marginal sample is also taken from the caudal wound bed. The entire tumor specimen is thread-marked and sent for examination together with the edge specimens, which are also thread-marked. Tumor specimen on all sides in healthy tissue, thus including the margin samples. R0 situation. Careful hemostasis. Now tracheostoma creation: small Kocher collar incision. Subsequent exposure of the infrahyoid muscles, spreading them. Exposure of the thyroid isthmus. This is clamped off, severed and supplied by means of puncture ligatures. Opening of the second/third intercartilaginous space, wide modified Björk flap, which is epithelized. Re-intubation. Now elevation of the radialis flap from the right side: marking of the flap after its dimensions have been measured transorally. Flap length almost 16 cm wide, 10 cm in the largest dimension. Mark the flap on the forearm. Then unwrap the arm and apply a tourniquet. Cutting around the flap from the ulna, later also from the radial side. Skin incision also curved towards the elbow. Subfascial lifting of the flap from distal to proximal. Proximally, the radial artery is removed and supplied with puncture ligatures. Outgoing vessels are clipped or supplied bipolar. Flap pedicle is identified and visualized under the brachioradialis. The superficial venous system is also visualized. Connection between the superficial and deep venous system in the crook of the elbow. This is visualized. A cephalic vein with two thick ends can be visualized. Walls very thick. Very thin accompanying veins on the radial artery, which are not capable of anastomosis. The interosseous artery was removed. Good reperfusion after opening the tourniquet. Longer reperfusion time. Subsequent removal of the flap. Veins are ligated. The outlet of the radial artery is treated by puncture ligation. The flap is then removed and heparin flushed. Vein lumen extremely narrow with very thick walls and equipped with valves. Therefore, shortening of the veins and ....................... division of the cephalic vein, then irrigation possible. Subsequent successive suturing of the flap into the defect according to its three-dimensional configuration using 3.0 Vicryl single-button sutures. Low-tension defect coverage. Complete closure. Then conditioning of the vessels. There is a small residual high-lying outlet on the internal jugular vein. However, the outlet is the appropriate size and is virtually located on the trunk of the internal jugular vein. The facial artery is selected for the arterial anastomosis. Here the lumen is too thin with a very thick muscular wall. Dissection up to the exit of the external carotid artery. The common trunk of the facial and lingual arteries can be visualized here. Anastomosis with the conditioned radial artery using 9.0 Ethilon sutures. After opening the clamp, good arterial flow, good venous return. As a venous anastomosis, an attempt is first made to anastomose a venous outlet from the flap pedicle with a high-set outlet very close to the internal jugular vein. This is not successful because the vessel wall is very thin and tears out. Therefore, first anastomosis of the second outlet from the flap stalk with the external jugular vein, which has already been partially anastomosed after ligation. This can be made pervious again after flushing with heparin. An anastomosis is created using a 2.5 mm coupler. Good venous return. Positive smear phenomenon. Subsequently, due to the unsatisfactory first anastomosis, creation of a second venous anastomosis. No further outlets were found on the internal jugular vein. This is therefore removed and connected to the second venous stump via a 2.5 mm coupler. Good venous return here too. Positive smear phenomenon. Overall flap now vital and well perfused. Careful hemostasis, irrigation of the wound area on both sides, closure of the wound on both sides with insertion of a Redon drain on the right and a flap on the left. An 8-gauge tracheostomy tube is inserted and sutured. The forearm is covered using a split-thickness skin graft from the right thigh. For this purpose, an appropriately sized split-thickness skin graft of maximum thickness is removed using the dermatome. Hydrogel dressing is applied to the thigh. Work the split skin into the defect. The cranial wound is closed in layers in the typical manner. Complete defect coverage. Application of a hydrogel-Mepilex dressing. Loosely applied compresses are placed on top. Absorbent cotton dressing. Fixation of the arm using a loosely applied Cramer splint. Further inspection of the flap. This is vital. The procedure is completed without complications. Patient goes to the intensive care unit for postoperative monitoring. Please continue heparin perfusor as started intraoperatively for 5 days at 500 units per hour. Please continue antibiotics started intraoperatively for 2 to 3 days postoperatively. Nutrition for 7 to 10 days via the inserted PEG tube. Flap control according to the scheme for 5 days. 30 degrees elevation. Overall cT3 to 4 min. cN2b oropharyngeal carcinoma on the left. Postoperative radiochemotherapy probably required. Please present the patient to the interdisciplinary tumor conference after receiving the final histology.