First, pharyngoscopy again: The exophytic tumor in the area of the tonsil lobe with transition to the palatal arch is confirmed, smaller flat extensions caudally onto the lateral wall of the oropharynx and towards the posterior wall of the oropharynx are visible. Therefore indication for surgery confirmed. PEG insertion: insertion of the flexible esophagoscope. After creating the diaphanoscopy, insertion of a 15 mm abdominal wall tube in a typical manner without complications. Positioning of the patient. Skin disinfection. Injection of a total of 20 ml Ultracaine 1% with adrenaline into both sides of the neck. First start with radical neck dissection on the right: skin incision typically widened slightly caudally. Depiction of the sternocleidomastoid muscle. This is infiltrated by lymph node metastases. Showing digastric muscle, omohyoid muscle. Depiction of the internal jugular vein, which is infiltrated cranially by the metastasis. Depiction of the common carotid artery, internal/external carotid artery. These can be dissected from the metastatic conglomerate. Depiction of the hypoglossal nerve. This must also be dissected. The nervus accessorius extends into the lymph node conglomerate and is also resected. Some branches of the cervical plexus, which are involved in the tumor, must also be resected in the cranial to middle area. The sternocleidomastoid muscle is removed caudally and cranially and also resected. Parts of the deep neck muscles in the cranial area must also be resected as they are also infiltrated. The internal jugular vein is removed caudally and cranially and ligated twice. However, the most caudal part of the internal jugular vein with an outgoing facial vein can be preserved for the vascular anastomosis. Vagus nerve border cords are exposed and preserved. Neck dissection on the left, performed by <CLINICIAN_NAME>: Skin incision in typical manner. Exposure of the sternocleidomastoid muscle. Depiction of the omohyoid muscle, digastric muscle. Exposure of the internal jugular vein, facial vein, internal/external carotid artery, vagus nerve, accessorius nerve and hypoglossal nerve. All structures are visualized and preserved. Clearing from level II to V. This is also done while exposing and preserving all branches of the cervical plexus. Finally, careful hemostasis and wound closure in the typical manner with insertion of a Redon drain. Tracheostoma creation: Small Kocher collar incision. Dissection through subcutaneous tissue to the infrahyoid musculature. This is split. Thyroid isthmus, which is very small, is dissected after bipolar coagulation. The anterior wall of the trachea is exposed. The trachea is opened in the 2nd to 3rd intercartilaginous space and a wide-based, modified Björk flap is created. This is epithelized in the typical manner. Subsequently, reintubation with insertion of a Woodbridge tube. Then tumor resection combined transorally and transcervically: The tumor is first removed macroscopically from all sides transorally at a distance of at least 1 cm. The anterior palatal arch is completely removed and parts of the posterior palatal arch are removed. The tumor is removed along the tonsil capsule, as this is a good boundary layer. Glossoalveolar groove, marginal parts of the base of the tongue and the pharyngeal side wall up to just before the entrance to the hypopharynx are also removed. Tumor specimen is thread-marked and sent for frozen section. Similarly, a marginal sample from the medial edge of the pharyngeal wall at the border to the posterior wall. This is also thread-marked and sent for final histology. Here, there are very narrow gaps in the basal direction, so that a resection is recommended. Carcinoma in situ infiltrates are also found in the middle section of the marginal specimen in the medial direction of the pharyngeal wall, so that a resection is also necessary here. For the resection, the internal/external carotid artery was previously dissected and the kinking of the internal carotid artery was also separated from the pharyngeal wall. All soft tissue is now removed from the inside of the lower jaw from the cranial side next to the palatal arch down to the hyoid bone. All soft tissue remaining from the pharyngeal tube is removed. A wide resection is also obtained from the medial pharyngeal wall, which is marked with sutures remote from the tumor. The soft tissue margin sample and the margin sample from the medial pharyngeal wall are sent to the frozen section again. Here, no further tumor infiltrates are visible in the soft tissues. Only moderate dysplasia on the pharyngeal wall, no carinoma in situ. Thus now an R0 situation. There is a defect from the palatal arch next to the uvula down to the piriform sinus entrance. As no radial flap is possible, a thigh flap is removed to cover the defect: Several perforators can be made out in the line from the superior spina to the lateral patella and these are marked. After measuring the size of the flap, the dimension is 13 x 8 mm. This flap size is marked around the perforators accordingly. First make a skin incision medially up to the fascia. Then cut through the fascia. Depiction of the rectus femoris muscle. Incision is extended slightly cranially, between rectus femoris and vastus lateralis to find the ramus descencus. However, this does not run directly next to the vastus lateralis but into the muscle at the lower edge of the vastus lateralis. Departure of several perforators can be observed. Separation of the vastus in the medius from the intermuscular septum. The vascular pedicle is followed distally. Here the vascular pedicle is deposited in the caudal region. Then make a skin incision on the lateral side up to the fascia. After cutting through the fascia, successive lifting of the flap with muscle cuff. This muscle cuff is slightly enlarged as the vessels run into it from the caudal instead of the lateral side. Successive lifting of the muscle. Branches of the femoral nerve to the muscles are all preserved as far as possible. Subsequent dissection of the vascular pedicle up to the entrance of the artery into the profunda femoral artery. Outgoing smaller arterial vessels are ligated or clipped. Two accompanying veins are also lifted, outgoing vessels are ligated or clipped. Cranially, a confluence is divided into three outgoing vessels in front of the entrance to the femoral profunda vein. After complete elevation of the flap including the pedicle, there is good pulsation in the area of the descending ramus and at least two of the outgoing perforators. Blood flow in the flap is regular. Subsequently, the artery, which is cut off cranially with 4.0 prolene sutures, is removed using the puncture technique. The smaller outgoing veins are ligated. The outlet from the profunda femoral vein is treated with 4.0 prolene sutures over and under the vein. After removal of the flap, irrigation with heparin. The wound on the thigh is closed in layers after extensive hemostasis. The fascia is also sutured. Wound closure with insertion of two Redon drains. Now suture the flap into the defect. The flap is inserted into the neck in such a way that excessive tension between the skin and muscle in relation to the perforators is avoided. Successive suturing of the flap into the defect using 3.0 Vicryl single-button sutures, which is partly done by advancing the sutures. The flap can be sutured into the defect with relatively little tension and in a three-dimensionally correct manner. The vessels are then trimmed for the vascular suture. The facial artery is selected. This is sutured to the descending ramus after widening the lumen of the facial artery using the fish-mouth technique with 8.0 Ethilon single-button sutures. Trimming of the veins. The facial vein, which opens caudally into the still open internal jugular vein, is selected. This is anastomosed with the confluent vessel from the profunda femoral vein. A coupler size 3.0 is selected for this purpose. After opening the arterial clamp, good venous return or after opening the veins, good venous return, smear phenomenon positive. However, pulsation via the perforators is relatively weak. ......... Control brings little reflux. Disturbance in the perforator area, e.g. spasm, cannot be ruled out with certainty, but pulsation via the anastomoses and the large vessels is regular. Further measures currently not advisable. Therefore now careful hemostasis. Wound closure in layers with insertion of a flap. Skin closure on the left is also performed after hemostasis and insertion of a Redon drainage. Insertion of a size 8 tracheostomy tube, which is fixed with sutures. Completion of the procedure without complications. Overall cT2-3 tonsil/oropharyngeal carcinoma on the right. cN2b status required radical neck dissection. Defect coverage by means of thigh flap from the right side. Circulatory situation uncertain at the end. Patient transferred to the intensive care unit for monitoring. Here regular checks of flap perfusion according to schedule. Heparin perfusion, which was started intraoperatively at 500 units per hour, should be continued. Please continue antibiotics, which were started intraoperatively with Unacid, for one week. Feeding via the inserted PEG tube. Flap insufficiency due to perforator insufficiency possible, then defect closure preferably by means of pecoral major flap according to the clinical course.