First of all, pharyngoscopy again after positioning the head: The exophytic tumor can be seen, which is massively located at the described site. Mucosa in the area of the arytenoid fold on the left and postcricoid area edematously thickened. Indication for surgery confirmed. Flap cover with platysmal flap or radial flap probable. Initially in further positioning of the patient. Injection of the corresponding surgical regions and sterile draping after skin disinfection of all regions relevant to the operation. Initially start with an apron flap, which is extended to the left latero-caudally in order to cover the defect with a platysmal flap if necessary. Lift this apron flap subplatysmally in the area of the platysma with underlying fatty tissue on the left side. The external jugular artery is ligated and taken along, paying particular attention to the venous outlets, especially connections to the external jugular vein, anterior jugular vein and facial vein. The apron flap is raised on both sides to the level of the submandibular gland or the level of the hyoid bone. Then neck dissection on the left: Exposure of the sternocleidomastoid muscle anterior border and dissection of the fat lymph node package. Exposure of the internal jugular vein, facial vein. Exposure of the internal carotid artery, externa. Exposure of the vagus nerve border cord, accessorius nerve and hypoglossal nerve. Subsequent evacuation level II to V with visualization of the branches of the cervical plexus which are preserved as far as possible. Subsequent tumor resection via lateral pharyngotomy. Pushing the hypoglossal nerve cranially. Push off the cervical vascular sheath laterally, ligation of the lingual artery. Exposure and preservation of the superior thyroid artery and pushing the thyroid gland in the upper pole latero-caudally. Exposure of the pharyngeal tube. Tumor can be felt massively next to the thyroid cartilage or on the thyroid cartilage. Insertion next to the epiglottis. Expose the tumor successively, cut around the tumor with a safety margin of at least 1.5-2 cm on all sides. The lateral part of the aryepiglottic fold falls caudally to the piriform sinus, medially to the posterior pharyngeal wall and cranially to the beginning of the tonsillar lobe, in each case the entire diameter of the pharyngeal wall. The thyroid cartilage is resected paramedian to the left and just above the beginning of the cricoid cartilage. The specimen is removed and marked with sutures. Carcinoma in situ or small foci, in this case infiltrates, are still recognizable in 2 places in the area of the arytenoid fold and in the area of the base of the tongue to the posterior pharyngeal wall despite the wide resection distance. Therefore, resection of a strip of mucosa at least 1 cm wide from the base of the tongue over the posterior pharyngeal wall to the transition to the piriform sinus. The specimen is marked with sutures away from the tumor. Further resection with removal of the mucosa in the area of the aryepiglottic fold, also a good cm wide up to the entrance to the piriform sinus. Here too, suture markings remote from the tumor. In the frozen section now at most low to moderate grade dysplasia, no carcinoma in situ or invasive carcinoma. Therefore now R0 resection. Neck dissection is now performed on the right side. Here too, removal of levels II to IV as well as parts of 5. Exposure of the structures as on the opposite side. All structures are also preserved as far as possible, especially the vessels. Then tracheostoma creation: The infrahyoid muscles are cut caudally. The thyroid isthmus is then passed underneath, clamped, severed and supplied by means of puncture ligatures. Exposure of the trachea . Wide pedicled modified Björk flap. Epithelialization of this initially caudally. Re-intubation and insertion of an 8 mm Woodbridge tube. The radial flap is removed: After measuring the size of the defect, the flap size is just under 11 x just under 7 cm. Marking on the forearm. Curved skin incision up to the crook of the elbow. First release the flap from the ulnar side while protecting the ulnar artery. Flap elevation subfascially. Subsequent cranial exposure of the superficial vascular system, which remains intact. Subsequent incision of the radialis flap from radial, subfascial. Exposure and preservation of the lateral antebrachial cutaneous nerve. After clamping the radial artery, remove it caudally and ligate. Then lift the flap subfascially with the vascular pedicle. Smaller vessels are bipolarly coagulated or supplied with clips. A variation then becomes apparent in the further course. The radial artery runs under the pronator teres muscle a little further caudally into the brachial artery. The confluence runs under the muscle in the direction of the superficial venous system, which runs above the muscle to the crook of the elbow. Decision to separate the superficial venous system from the deep one after a good confluence could be visualized below the pronator teres muscle. A. radialis is visualized at the entrance to the A. brachialis; the A. interossea, which is first clamped off, is first removed. Saturation at 100 % in each case. Deposition of the interosseous artery. Separation of the brachial artery at the entrance to the brachial artery. Treatment of the site of detachment with 6-0 Vascufil sutures. Subsequent stable saturation in the forearm area. Subsequent removal of the confluence below the pronator teres muscle and removal of the superficial veins with 2 connection options with splitting of the cephalic vein. The veins are ligated cranially. Flap pedicle is flushed with heparin via the superficial deep vein system and via the artery and preserved. Subsequent closure of the forearm defect: A piece of split skin is removed from the thigh area, thickness 07 to 08 mm. The thigh area is treated with a hydrocolloid dressing. Split skin is successively worked into the skin defect. The cranial skin wound is closed in layers. Subsequent octenidine-Mepilex dressing. Loose cloud dressing. Loose absorbent cotton dressing on loosely inserted compresses. Then fit Cramer splint and fix splint with tape bandage. Saturation on the forearm or thumb area always at 100%. Subsequent suturing of the flap into the defect: Radialis flap is inserted into the defect in such a way that the flap stem can be passed through a tunnel underneath the infrahyoid muscles to the opposite side. Successive suturing of the flap into the defect using 3-0 Vicryl single button sutures without tension. Flap is sutured to the remaining thyroid cartilage or laterally to the remains of the previously resected hyoid bone on the left. The epiglottis is not included in the suture so that it remains mobile. Complete tension-free closure. The flap pedicle is then passed underneath the infrahyoid muscles to the opposite side. Conditioning of the superior thyroid artery, which can be anastomosed with 9.0 Ethilon single-button sutures. After opening the clamps, good arterial flow and good venous return. The confluent vein is anastomosed to a facial vein with 2.5 couplers. Here too, after opening the clamps, good venous flow, positive smear phenomenon. Next, anastomosis of an outlet of the cephalic vein with the external jugular vein via 3.5 couplers. Here too, good venous return, positive smear phenomenon. The remaining outlet is treated close to the outlet using clips. Subsequent careful irrigation of all regions in the neck area. Hemostasis. Insertion of a Redon drain on both sides, guided on the right. Successive layer-by-layer skin closure with incision of the apron flap with epithelialization of the tracheostoma. The skin in the area of the pre-platysmal flap was somewhat livid during the operation and was therefore not used to cover the defect, but had recovered by the end of the operation. Overall, radial flap coverage was indicated due to the size of the defect. Finally, insertion of an 8 mm tracheal cannula, which is fixed with sutures. The procedure was completed without complications. Doppler signals and flap perfusion normal. Patient goes to intensive care unit for postoperative monitoring. Please elevate to 30°. Heparin perfusor 500 E/hour which was started intraoperatively please continue postoperatively for 5 days. Regular checks of the flap via transoral inspection or Doppler signals according to the scheme. Antibiotics started intraoperatively should be continued postoperatively with Unacid for approx. 1 week. Overall hypopharyngeal carcinoma with invasion into the lateral laryngeal region. Therefore, in addition to the hyoid bone on the left, thyroid cartilage on the left was also resected. Overall, however, a larynx-preserving procedure was possible and defect coverage using a radial flap was indicated. Postoperative presentation in the interdisciplinary tumor conference according to the histological findings. Nutrition via the inserted PEG tube. On the 10th postoperative day, gruel swallowing and, if necessary, diet build-up. Due to the position of the tube and the resection, protracted dysphagia is to be expected, therefore early initiation of swallowing therapy or swallowing rehabilitation.