After preparation and intubation by the anesthesia colleagues, the patient is first positioned. Entry with the Kleinsasser tube under dental protection. The oral cavity is largely unremarkable. In the area of the right oropharynx, the right tonsil is clearly hyperplastic and irregular in a lateral comparison. Inspection reveals a clearly discontinuous growth. There are numerous perifocal carcinoma islands, especially in the direction of the posterior palatal arch to the posterior pharyngeal wall and clearly scattered beyond the caudal end of the tonsil region to the lateral pharyngeal wall. Now described as extending to the glossotonsillar groove, no tongue infiltration. Palpatorily no extensive deep growth. However, the area of the discontinuously growing tumor corresponds to the tumor extent cT3, palpatory right-sided conglomerate-like metastases, especially in level II, moderately displaceable. The PEG tube is inserted first. Insertion with the gastroscope under laryngoscopic control. Easy pre-scanning into the stomach. If diaphanoscopy is excellent, the stomach can be punctured without any problems. Subsequent placement of the PEG tube using the usual thread pull-through method. Subsequent preparation and repositioning for initial transoral tumor resection. Incision of the tumor with a safety margin of at least 1 to 1.5 cm, including the anterior soft palate and anterior palatal arch. Resection to parauvular level. Resection over the posterior palatal arch up to the middle of the posterior pharyngeal wall. Resection in depth, including the posterior palatal arch and the adjacent muscles. Inclusion of the glossotonsillar groove, resection up to the alveolar ridge mucosa. The transorally resected part of the tumor is now completely covered, including basally with margin samples. This shows an in sano resection for the invasive carcinoma, but longer residual Cis in the soft palate area. In the meantime, neck dissection of the right side and preparation for transcervical completion of the tumor resection had already been performed. For this purpose, a skin incision was made on the anterior edge of the sternocleidomastoid muscle. Separation of skin and subcutaneous tissue. Separation of the platysma. Exposure and preservation of the auricularis magnus nerve. Exposure of the sternocleidomastoid muscle, omohyoid muscle, submandibular gland and digastric muscle. Clearing of the anterior neck preparation with careful preservation of the hypoglossal nerve, superior thyroid artery and the powerful facial vein. The conglomerate described above is now visible in the jugular-facial angle. The largest mass measures approximately 5 cm. Careful solution. There is no infiltration of the surrounding structure. Complete preservation of the structures is possible. Also preservation of the accessorius nerve. Complete the neck dissection with clearing of the accessorius triangle and level Va while carefully preserving the nerve and the cervical plexus parts. The external and internal carotid arteries are now completely exposed. Resection of the posterior digastric muscle, release of the submandibular gland with resection of level Ib and protection of the marginal mandibular ramus. The pharyngotomy is now performed via the tonsil lobe and additionally via the submandibular and connection of the pharyngeal openings and successive exposure of the tumor. Resection of the tumor in toto, also maintaining an adequate safety margin. The entire caudal tumor is now also imaged with marginal specimens. In addition, a generous resection is performed in the area of the soft palate, as is the renewed removal of margin samples. All marginal samples were found to be free of carcinoma and without evidence of higher-grade dysplasia, meaning that the overall situation is now R0. The defect was then measured and the decision was made to reconstruct the defect with the antero-lateral thigh graft due to the size of the defect, extensive pharyngeal resection extending into the vallecula and piriform sinus entrance. The neck dissection of the left side is performed first. To do this, make a skin incision on the anterior edge of the sternocleidomastoid muscle. Old auricularis magnus nerve. Exposure of the sternocleidomastoid muscle, omohyoid muscle, submandibular gland and digastric muscle. Release of the anterior neck preparation with careful protection of the superior thyroid artery, facial vein, hypoglossal nerve and cervical vein. Free preparation of the internal jugular vein. Clearing of the accessorius triangle with careful protection of the nerve, clearing of level V with careful protection of the cervical plexus branches without evidence of caudal lymph leakage. The wound is then carefully inspected. Wound irrigation and, if the wound is dry, insertion of a 10-gauge Redon drain and careful two-layer wound closure. The tracheotomy is then performed due to the extensive defect. Horizontal skin incision below the cricoid cartilage. Cut through the skin and subcutaneous tissue. Exposure and transection of the infrahyoid musculature. Exposure of the cricoid cartilage, exposure of the anterior surface of the trachea. Dissection of the thyroid isthmus. Entering the 2nd and 3rd tracheal ring. Creation of a broad-based pedicled Björk flap and insertion of the tracheostoma in the usual manner. Subsequent problem-free transfer to a 9 mm low cuff cannula. The antero-lateral transfemoral graft is then removed. After marking the landmarks and doppler sonographic identification of the main perforator and 2 strong secondary perforators, the graft measuring up to 12 x 7 cm in total is marked with a special soft palate configuration. First medial incision, cutting through skin and subcutaneous tissue. Separation of the fascia lata. Identification of the rectus femoris muscle. Strict subfascial dissection and identification of the S-stem. The anatomy is largely regular with a perforator branching off the ramus descendens and a circumscribed intramuscular perforator course. The relief incision is now made. Dissection of the vascular pedicle, complete resection of the graft. Removal of the fascial ata. Dissection and removal of the peripheral vascular pedicle. Subsequent elevation of the graft, leaving a small muscle cuff in the area of the outgoing perforator. Subsequent isolation onto the vascular pedicle. Exposure and entrainment of a slightly weaker accompanying vein and placement of the graft with regular blood flow after ligation. Then, if the wound is dry, adjust the wound edges and carefully close the wound in two layers after inserting a 10-gauge Redon drain. Subsequent application of the graft. This is done transorally and transcervically. Finally, good fit and intact conditions on all sides. Conditioning of the superior thyroid artery and the facial vein. Performing the arterial anastomosis with 8.0 Ethilon. This was successful and sufficient. Immediate regular venous return. Subsequent conditioning of the facial vein. Measuring a coupler size 4.0 and performing the venous anastomosis with the coupler system. Followed by regular .......pulsation. Positive spreading phenomenon. Excellent graft perfusion so that the stalk is then positioned. Then, with dry wound conditions, insertion of a 10-gauge Redon drain and careful two-layer wound closure. Final inspection and completion of the procedure with a vital graft. The patient received intraoperative intravenous antibiotics for 24 hours. Conclusion: Intraoperatively R0 resected discontinuously growing right oropharyngeal carcinoma resembling cT3 cN2b. Defect reconstruction using ALT on the right. If the graft has healed properly and is intact, a diet can be started from the 8th postoperative day. Continuation of intravenous antibiotics with Unacid 3 g for 24 hours. After receiving the definitive histology, presentation at the interdisciplinary tumor conference to plan the adjuvant therapy that will certainly be required.