Induction of anesthesia by the anesthesia colleagues. Then sterile washing and draping of the neck. Entry with the Kleinsasser tube and inspection of the hypopharynx and larynx. There is an exophytic mass at the base of the tongue on the left side, which extends down to the pocket fold. The vallecula and epiglottis are completely consumed. The tracheotomy was then performed. Wash down the neck area. Mark the skin incision below the cricoid cartilage, where the apron flap will later be made, and dissect down to the trachea. Dissection of the muscles and insertion between the 2nd and 3rd tracheal cartilage and creation of a visor tracheostomy. Subsequent tracheostoma placement: here dictated by colleagues. Neck dissection on the right and removal of split skin from the right thigh by <CLINICIAN_NAME>: Now start of the operation with marking of the skin incisions. These run symmetrically on the left and right side of the neck like an apron flap over the sternocleidomastoid muscle on both sides up to the jugulum. Ending approx. 2 cm from the tracheostoma on both sides. The apron flap is then formed with an incision through the subcutaneous tissue and through the platysma. The platysma is then dissected on both sides in a cranial direction towards the hyoid bone and mandible. Carefully dissect and protect the venous vessels. The neck is massively scarred on both sides following radiochemotherapy. Now simultaneous neck dissection on both sides, left through <CLINICIAN_NAME>, right through <CLINICIAN_NAME>. Neck dissection on the right: First dissection of the sternocleidomastoid muscle, the omohyoid muscle up to the hyoid bone as well as finding and exposing the posterior digaster venter muscle. Dissection of the anterior edge of the sternocleidomastoid muscle and most careful dissection along the internal jugular vein to the facial vein and dissection of the facial vein. Exposure of the cervical profunda. Exposure of the deep plexus branches and the accessorius nerve. Later exposure of the hypoglossal nerve. Dissection of the common carotid artery and the internal and external carotid arteries. Later exposure of the neck vessels through <CLINICIAN_NAME> and <CLINICIAN_NAME>. Removal of the sparse lateral and anterior neck dissection. Neck dissection on the left: Then creation of an apron flap in the usual manner, this is already relatively difficult as the neck is severely altered postradiogenically. The patient has an extremely thin platysma. Finally, it is possible to dissect the apron flap upwards. Then start with the neck dissection on the left side. The neck vessels and the entire area are heavily scarred. There is relatively little fatty tissue on both sides of the neck, exposing the sternocleidomastoid muscle, the omohyoid muscle, the submandibular gland and the digastric muscle. Then exposure of the cervical vascular sheath, this is extremely difficult in the patient due to the scarred conditions. Finally, removal of a very narrow neck preparation while sparing the plexus branches. Removal of the split skin from the right thigh and closure of the forearm wound with suturing of the split skin. by <CLINICIAN_NAME>: While <CLINICIAN_NAME> lifts the radialis flap on the left and a defect measuring 16 x 10 cm was measured here, the split skin with the dermatome is now removed from the right thigh. To do this, a strip of split skin approx. 20 cm long and a maximum of 7.5 cm wide is first lifted. As this tears slightly in several places, a second strip of split skin approx. 10 cm long and 7.5 cm wide is removed with the dermatome. Then hemostasis with starch powder and Mepilex dressing system. Now suture the split skin on the left forearm. Here, Vicryl 5-0 perichondrium is first sutured over exposed tendons in several places. The subcutaneous suture and the skin suture are then performed proximally in two layers. The longer split skin strip is then sutured in the middle and proximally to distally with 5-0 Ethilon. An additional strip of split skin approx. 6 x 2.5 cm long must then be sutured in on the ulnar side, also with 5-0 Ethilon. Another strip approx. 8 x 3 cm long must be covered with split skin on the radial side. The three pieces of split skin are also sutured together with Ethilon 5-0. Subsequently, relief incisions are made so that any hematoma or seroma can drain away. Preparation swabs are inserted to prevent the graft from lifting and the dressing is applied. Subsequently, combined transoral-transcervical tumor resection: Start with the tumor resection from the transoral side to mark the tumor there. In the area of the base and edge of the tongue, including the anterior palatal arch, a sample was taken and squamous cell carcinoma was found, which meant that most of the palatal arch on the left side had to be removed as well as large parts of the uvula and the tonsil region. Then further dissection from the transcervical side, where 2/3 of the tongue at the base of the tongue had to be resected, leaving only a narrow strip on the right side. However, the lingual artery can be safely preserved and also ensure blood supply to the tongue. The tumor extends caudally into the pocket fold region and also involves the entire epiglottis and the vallecula. This must be removed up to the petiolus. Ultimately, only the level of the vocal folds remains of the larynx and there are no protective mechanisms left to protect the patient from aspiration; this finding is demonstrated intraoperatively on <CLINICIAN_NAME>, <CLINICIAN_NAME> and <CLINICIAN_NAME>. A joint decision is made to remove the larynx. The patient has previously given her verbal consent. This procedure was also discussed verbally with the relevant GP in advance. Then removal of the larynx. The corresponding 15 x 10 cm defect is then covered by <CLINICIAN_NAME> with a radial lobe graft. Subsequent removal of the radial lobe by <CLINICIAN_NAME>: Attachment of the arm. Measurement of the defect. This has a length of 15 to 16 cm and a width of 10 cm. Flap is planned in its three-dimensional configuration and size and drawn on the forearm. The flap is then first cut radially. Lifting subfascially. Cut to the crook of the elbow. Expose the superficial venous system and connection to the deep venous system. 1 to 2 outlets of the cephalic vein and a good confluence can be visualized. Then cut around the flap radially. Lift off subfascially, taking care to ensure that tissue remains on the tendons, as on the ulnar side. The radial nerve with its ramus cutaneus antebrachii lateralis is preserved as far as possible. Exposure of the radial artery distally. Clamping. Good saturation after an adequately long clamping time. Dissection of the artery, treatment using 4-0 Prolene puncture ligatures. Then lift the flap along the pedicle. Smaller vessels are bipolarly coagulated or clipped. The interosseous artery is first clamped and then clipped while maintaining good saturation. Subsequent exposure of the pedicle vessels. Removal of the veins, which are ligated. Subsequently, the artery, which is supplied with 6-0 Vascufil suture, is removed. Extensive irrigation of the radial artery flap with heparin. Removal of split skin from the thigh area in the corresponding size of the defect. Suturing of the flap by <CLINICIAN_NAME>: Successive suturing of the flap. The defect extends from next to the esophageal opening to the nasopharynx. The flap is sutured successively into the defect in the required three-dimensional configuration. Tension-free and complete defect coverage is achieved. The flap is then anastomosed. Both sides of the neck must be explored extensively for this, as the vessels sometimes carry no blood at all or are thrombosed after brief clamping. Finally, the superior thyroid artery on the opposite side can be dissected. This shows good blood flow even after opening and clamping. Slight incision of the lumen of the vessel like a fish mouth. The superior thyroid artery is then anastomosed with the radial artery after appropriate conditioning using 9-0 Ethilon single-button sutures. After opening the clamps, good arterial flow and good venous return. 2 venous anastomoses are created. A large outlet in the area of the confluence is anastomosed with an outlet from the facial vein, after appropriate conditioning, using a 2.5 mm coupler. Outlets at the facialis or smaller outlets in the area of the confluence are clipped. The cephalic vein is trimmed and anastomosed with the external jugular vein. To do this, the external jugular vein must be further mobilized to lengthen it and the sternocleidomastoid muscle must be partially severed to ensure a tension-free anastomosis. This can be created with Coupler 2.0 mm after appropriate conditioning of the veins. Here too, after opening the clamps, as with the previous vein, good venous flow and positive smear phenomenon. Subsequent careful irrigation of the wound area. Intraoperative flap check shows good blood flow. If the site is free of bleeding, the wound is now closed in the typical way in layers with epithelialization of the tracheostoma and insertion of a Redon drain on the left and 2 flaps on the right. Another intraoperative check of the flap transorally. This is well perfused. Then removal of the laryngectomy tube, insertion of an 8-gauge tracheostomy tube and fixation with sutures. The procedure is completed without complications. The patient is transferred to the intensive care unit on a ventilator for monitoring. Please continue the antibiotic treatment, which was started intraoperatively, for 1 week with Unacid. Feeding via the PEG tube for at least 2 weeks, then gruel and, if necessary, cautious diet build-up. Flap control in typical manner for 5 days closely meshed by means of clinical control and Doppler sonography. Total of T4 residual tumor treated by salvage resection and radial flap.