Induction of anesthesia and intubation by anesthesia colleagues. Injection, sterile washing and draping. The tumor is first inspected with the Kleinsasser tube. The tumor starts at the tonsil loge on the right side, moves caudally along the pharyngeal side wall, infiltrates the entire piriform sinus on the right side including the tip of the piriform sinus, spreads from the piriform sinus to the larynx and infiltrates the postcricoid region, pocket folds and vocal fold and also moves into the esophageal entrance via the piriform sinus. Start the operation by creating an apron flap in the usual way. Release of the larynx. Start at the hyoid bone on the left side. The hyoid bone cannot be completely detached on the right side, as the tumor is already infiltrating the hyoid bone and soft tissue on CT morphology, so half of the hyoid bone must be detached on the left side and the rest is left in situ. Release of the larynx initially on the left side. Detachment of the oblique laryngeal muscles. Removal of the piriform sinus and detachment of the thyroid gland. Also detachment of the thyroid gland on the right side. Detachment of the cervical vascular sheath from the pharynx and entry into the pharynx from the left side. Inspection of the tumor and resection of the tumor, including the lower pole of the tonsil and the entire pharyngeal wall on the right side. Removal of the larynx, including parts of the esophageal inlet. The tumor specimen is inserted en bloc into the frozen section. Macroscopically, there is a scarce resection in the area of the piriform sinus and the esophageal duct. Therefore, another resection is immediately performed here and a new marginal sample is taken. No dysplasia, no carcinoma in situ and no invasive carcinoma in the resected specimen or in the new marginal specimen. Final margin samples R0 on all sides. Inspection of the mucosa in the area of the caudal mucosal part and esophageal entrance, relatively little mucosa is present, as well as upwards towards the tonsil lobe. Intraoperative demonstration of the defect on <CLINICIAN_NAME>. A joint decision is made to insert a radialis graft. The defect is measured, 18 x 8 cm with a bulge at the tonsil lobe. This graft is lifted on the forearm by <CLINICIAN_NAME>. Removal of the radialis flap. Removal of the radial graft on the right arm by <CLINICIAN_NAME>. Measurement of the defect and removal of a 15 x 8 cm radialis graft from the right forearm. To do this, mark the graft and the radial artery and ulnar artery. Then angulation of the forearm and dissection without tourniquet. Cut around the graft and extend the incision to the crook of the elbow. Exposure of the brachioradialis muscle. Exposure of the superficial ramus of the radial nerve. Exposure of the radial artery. Deposition and transposition of the radial artery after application of a vascular clamp for approx. 5 minutes. During this time, good oxygen saturation was measured on the index finger. Lift the graft from the tendons and dissect the pedicle in the usual manner up to the crook of the elbow. Dissection of the basilic vein and cephalic vein. Dissection of the venous confluence up to the deep venous system. Exposure of the interosseous artery and removal of the radial artery while preserving the interosseous artery. Removal of two superficial and two deep veins. Parallel to the harvesting, the split skin is removed from the thigh by <CLINICIAN_NAME> and <CLINICIAN_NAME>. Now close the wound on the right forearm with the removed split skin using <CLINICIAN_NAME> and <CLINICIAN_NAME> in the usual way. Insertion of swabs and application of a dorsal forearm splint. In the meantime, the neck dissection is performed on both sides. Start on the right side. Exposure of the sternocleidomastoid muscle, the omohyoid muscle, the submandibular gland and the digastric muscle. Free preparation of the internal jugular vein and the facial vein and release of the neck block II a to V a while sparing the plexus branches. Exposure of the sternocleidomastoid muscle on the other side. Exposure of the omohyoid muscle, the submandibular gland and the digastric muscle. Release the cervical vascular sheath and detach the neck preparation II a to V a while sparing the plexus branches. The neck vessels are now prepared microscopically, initially on the left side. However, during preparation it becomes apparent that the vessels on the left side are not suitable for anastomosis, so the procedure is switched to the right side. Here the superior thyroid artery is prepared, the facial vein and an outlet from the facial vein and the external jugular vein. Then, after removing the radialis graft, the graft is flushed with heparin, which can be done without any problems, and then the anastomosis of the artery and the two veins is started in the usual way. Suturing of the graft initially in the area of the oropharynx. The graft was configured in such a way that the tonsil lobe was given an extra bulge in the graft, and suturing began there. Then successive suturing caudally. In the area of the esophageal opening, a V-shaped esophageal opening plasty must be performed. To do this, a myotomy is performed on the dorsolateral side on the left and a slightly paramedian incision is made in the esophageal entrance on the right to create a V-shaped defect. The radial flap is inserted into this V-shaped defect like a jigsaw puzzle. Several sutures are placed and the graft is fixed in place with inverting sutures. Finally, the graft is completely sutured into place. A monitor was not used as the graft is too large to shorten the stalk any further and the flap can also be easily checked in the tonsil lodge by direct inspection. At the end, insertion of a Redon drain on the left side and a flap on the right side. Fold back the apron flap. Incision of the tracheostoma and two-layer wound closure. At the end, control Doppler sonography in the area of the flap stalk. Good Doppler signal and marking of the flap pedicle. The patient goes to the intensive care unit ventilated. Please carry out post-operative flap checks according to the usual schedule. Continue antibiotics for at least 24 hours, preferably longer. X-ray emulsion at the earliest on the 12th postoperative day. Please consult the surgeon beforehand.  