At the beginning of the operation, after intubation and induction of anesthesia, pharyngoscopy is performed to re-inspect the findings: Tumor growth starting from the tonsil with spread to the left soft palate to parauvular, but not involving the hard palate. The tumor growth also extends to the base of the tongue and covers approx. 1/4 to 1/3 of the base of the tongue on the left. Caudally, the tumor extends into the vallecula and just above the entrance of the piriform recess on the left side. Enorally, the tumor is first dissected in the area of the soft palate up to the transition to the base of the tongue. Due to the further deep extension and the poor visibility, it was decided to approach the further tumor resection via a lateral pharyngotomy, after appropriate left-sided neck dissection. To do this, first make a skin incision along the front edge of the sternocleidomastoid muscle. Cut through the platysma and dissect the vascular nerve sheath. Due to the extensive metastasis (cN2b) with infiltration of the sternocleidomastoid muscle, accessorius nerve and the cranial part, particularly in the area where the facial vein leaves the internal jugular vein, as well as the infiltration of the digastric muscle and individual branches of the external carotid artery, an extended radical neck dissection is performed. This is followed by dissection of the vascular nerve sheath in the caudal part, identification of the vagus nerve and the common carotid artery as well as the internal jugular vein. The internal jugular vein is set off on the left side above this after the vein leaves the thyroid gland. The sternocleidomastoid muscle is also removed caudally and cranially in the area of the mastoid. Bypass the digastric venter muscle posteriorly and remove the muscle. The internal jugular vein is also carefully exposed and ligated and cut at its entry into the jugular foramen. The tumor infiltrates the sympathetic trunk, so to speak, and this must therefore also be severed. The tumor cone can be removed directly at the level of the intervertebral foramen. The extensive metastasis can be resected macroscopically in toto, taking the accessorius nerve and cranial parts of the plexus with it. The branches of the facial artery and lingual artery are ligated and severed at the carotid artery. The entire course of the hypoglossal nerve is dissected and can be preserved. The vagus nerve is also dissected and can be preserved. Level Ib is also completely removed during the operation, taking the submandibular gland with it. The previously resected wound bed is now reached from the cervical side. The base of the tongue can be grasped with the tumor and can now also be bypassed in the middle and caudal part with excellent visibility. The entire specimen is then sent for histopathological examination. As there is carcinoma in situ between the pharyngeal wall and the entrance to the piriform recess, a thorough resection is carried out here again and a final marginal sample is taken. This is followed by the neck dissection on the right side: for this purpose, a skin incision is made along the front edge of the sternocleidomastoid muscle and the vascular nerve sheath is dissected. The external jugular vein and auricular nerve are preserved. Dissection along the omohyoid muscle to the hyoid bone and along the posterior digastric venter muscle to the laterobase. Lifting of neck block II, III and IV while preserving all nerve and vascular structures. Finally, elevation of level V with protection of the accessorius nerve and the cervical plexus. There are no macroscopically conspicuous lymph nodes here. Insertion of a 10 Redon drain, subcutaneous sutures and single button skin suture. Parallel to the right-sided neck dissection, the radialis graft is lifted from the left forearm. For this purpose, an individually shaped radialis skin graft is drawn in according to the defect and after appropriate measurement and lifted accordingly, using a skin monitor. The graft is lifted in a typical manner and the superficial ramus of the radial nerve is preserved. After previous lateral radial and ulnar dissection, the radial artery graft is now lifted subfascially while preserving the peritendineum from distal to proximal up to the ulnar bend. Dissection of the radial artery up to the confluence with the ulnar artery and the venae comitantes up to the confluence with a common vessel. Opening of the previously placed tourniquet and hemostasis. Removal of the radial artery graft and insertion of the radial artery graft from the outside to the inside and subsequent incision and reconstruction of the soft palate as well as the lateral pharyngeal wall and the base of the tongue with the preformed flap. The cranial part is incorporated enorally, the caudal parts via the pharyngotomy. The graft fits in without tension and is the ideal size. At the same time, full-thickness skin is lifted from the right groin. Careful hemostasis. Primary wound closure. An 8-gauge Redon drain is inserted into the right groin. The full-thickness skin is carefully thinned out and the lifting defect on the left forearm is partly covered primarily and partly with full-thickness skin. After appropriate incision of the full-thickness skin, application of a VAC pump, which should be left in place for 7 days. Application of a Cramer splint. Deposition of hand and forearm. Prior to this, a tracheostoma was created through a skin incision in the area of the jugulum. Dissection of the subcutaneous tissue and the infrahyoid musculature. Exposure of the thyroid isthmus, cutting through it. Exposure of the anterior wall of the trachea and creation of a caudally pedicled Björk flap. Careful suturing of the trachea to the skin. Re-intubation. Suturing of the cannula. After successful microvascular anastomization by end-to-end anastomosis of the flap artery with the superior thyroid artery (8/0 nylon) and the flap vein with the previously described thyroid vein outlet from the internal jugular vein (coupler 2,5 mm) and control of excellent arterial and venous flow as well as good coloration of the graft, a Redon drain is now inserted and the Redon drain is fixed in place with loops to prevent aspiration of the flap pedicle. After ensuring that the wound bed is dry, subcutaneous sutures and skin sutures are applied. Monitor the graft in the typical manner and avoid any dressings or bandages in the neck area. Keep the upper body elevated and the head straight. If there are any problems with the transplant, please inform the surgeon at all times.