First, after transnasal intubation and preparation by the anesthesia colleagues, positioning of the patient. First perform a pharyngoscopy. Enter with the small bore tube. Inspection of the inconspicuous oral cavity. A tumorous, exophytic area can now be seen, starting in the area of the tonsil lobe, which passes over the glossotonsillar groove into the base of the tongue, infiltrates the posterior floor of the mouth submucosally and extends caudally towards the pharyngoepiglottic fold. Overall, a well-defined tumor process. On palpation, however, the extensive submucosal growth from the posterior floor of the mouth and pharyngeal side wall towards the cervical region is conspicuous. Extensive tumor masses here. Transoral resection of the tumor is therefore performed first. Release of the paratonsillar tonsil ligament, initially leaving the posterior palatal arch intact. However, this is later resected transcervically. Widening of the safety margin. Resection up to the buccal. Release of the glossotonsillar groove and the posterior edge of the tongue. Resection towards the base of the tongue. Here, however, significant deep growth and submucosal growth. Therefore, the soft palate, the cheek, the posterior floor of the mouth and the edge of the tongue are now covered. These are assessed as completely free of carcinoma. Therefore, if there is extensive submucosal growth in the area of the floor of the mouth and the side wall of the pharynx, reposition for further transcervical resection. First make the skin incision, curved at the anterior edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Exposure and transection of the platysma. Exposure and preservation of the external jugular vein. Dissection 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, which is relatively strong here, the hypoglossal nerve and the cervical vein. Free preparation of the internal jugular vein. Here a few lymph nodes that are not necessarily suspicious macroscopically. Exposure of the accessor nerve. A round, rough and highly suspicious mass measuring approx. 3 x 3 cm can be seen below the accessorius nerve. Resection of the mass with careful protection of the nerve and preservation of the cervical plexus branches. Complete the accessorius triangle and level V while carefully preserving the nerve branches. Subsequent release of the submandibular gland. Exposure of the facial artery and vein first, later both are ligated and removed during the extension of the tumor resection. Complete exposure of the hypoglossal nerve. Resection of the digastric muscle. At the posterior margin of the submandibular gland, the submucosal part of the tumor is already visible. Clear tumor cone towards the cervical region. Widen the safety margin. Involvement of the posterior floor of mouth muscles. Entering enorally via the posterior floor of the mouth. Palpation now reveals a massive tumor block extending caudally over the lateral pharyngeal wall. Hence skeletonization of the hypoglossal nerve. Visualization of the cervical vascular sheath. Exposure of the prevertebral fascia from the cervical vascular sheath. This allows good mobilization of the tumour. Incision of the tumor with a safety margin and resection of the tumor including the posterior floor of mouth muscles and the pharyngeal side wall with a safety margin of a good 1 cm. Macroscopically clearly complete resection. Macroscopically slightly scarce conditions in the area of the posterior floor of the mouth with submucosal growth, but free marginal samples. Completely imaged margin samples are then taken. These are classified as completely tumor-free in the frozen section diagnostics. Finally, an extensive defect of the pharyngeal side wall with approx. 1/3 resection of the right-sided tongue base and resection of the posterior soft palate to parauvular, additional resection of the right tongue edge and the posterior floor of the mouth was found. Therefore, a graft of up to 13 x 10 cm in total is measured. First, however, the neck is dissected on the left side. Curved skin incision on the front edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Here in the cranial area after a previous operation with scarring. Exposure of the auricular nerve. An external jugular vein is not visible here. Exposure of the sternocleidomastoid muscle, the omohyoid muscle, the submandibular gland and the digastric muscle. Release of the anterior neck preparation with careful protection of the superior thyroid artery, the hypoglossal nerve and the facial vein. Free preparation of the internal jugular vein. Here a few macroscopically not necessarily suspicious masses. Exposure and preservation of the accessorius nerve. Release of the accessorius triangle with careful protection of the nerve and removal of level V with protection of the cervical plexus branches. Final wound inspection. If the wound is dry, wound irrigation, insertion of a 10 Redon drain and two-layer wound closure. The radialis graft is now removed from the left forearm and the plastic tracheotomy is performed in parallel. Firstly, the tracheotomy: After making a skin incision at the lower edge of the cricoid cartilage, cut through the skin and subcutaneous tissue. Exposure and transection of the infrahyoid muscles. Exposure of the cricoid cartilage. This is relatively deep. Exposure of the anterior surface of the trachea. Exposure of the thyroid isthmus. Dissection after ligation and coagulation. Exposure of the anterior surface of the trachea with a low trachea. Insertion between the 1st and 2nd tracheal ring. Creation of a broad-based pedicled Björk flap and insertion of the tracheostoma. Subsequent intubation with an 8-gauge Rüsch cannula, which is suture-fixed. Now to lift the radialis graft from the left: After marking the graft with a special configuration for the soft palate and base of the tongue, start with a tourniquet. Incision of the graft. Due to the size of the graft, a monitor is not lifted. First expose and remove the cephalic vein. Performing the...... ........ Maneuver to identify the ramus superficialis nervi radialis. Identification and visualization of the distal vascular pedicle. Cut after ligation. Ulnar release strictly subfascial with careful protection of the superficial ulnar artery, which is completely spared including the perivascular tissue. Strictly subfascial release of the specimen with release of the vascular pedicle. A small, medially pulling branch of the superficial radial nerve ramus must be resected, but the main trunk must be preserved. Proximal dissection with clipping of the descending pedicle vessels. Expose the brachial artery in the crook of the elbow with the exit of the powerful ulnar artery. The common interosseous artery arises here from the ulnar artery, therefore the radial artery can be dissected up to the brachial artery. There is a strong confluence of the accompanying radial veins here, but no bridge to the cephalic vein, so this is removed later. During the dissection, the massive truncal adiposity leads to insufficiency of the tourniquet. The tourniquet is therefore released again after approx. 20 minutes of preparation time. Elevation of the graft without blood lock without any problems. All-round vitality of the graft and regular blood supply to the hand until the graft is removed. Subsequent careful wound inspection. Hemostasis. Careful, two-layer wound closure and insertion of the full-thickness skin graft lifted from the right thigh. Subsequent application of the vacuum pump and application of the Kramer splint in the functional position and repositioning of the arm. Removal of the full-thickness skin graft: This is done in the case of pronounced fatty degeneration of the trunk. Removal of a full-thickness skin graft measuring approx. 16 x 8 cm. Resection of protruding, extremely large ......... fatty tissue. Resection of subcutaneous fatty tissue until multi-layer wound closure is possible without problems under moderate tension conditions. Prior to this, insertion of a 10 Redon drain. The graft is then inserted transorally and transcervically: this is laborious due to the size of the defect, but is ultimately successful with good reconstruction of the soft palate and extensive pharyngectomy. Reconstruction of the base and edge of the tongue. Regular check of fit and integrity. Subsequent conditioning of the flap vessels. Conditioning of the superior thyroid artery and the facial vein, which has excellent flow close to the outlet. Perform the arterial anastomosis with 8-0 Ethilon. This succeeds adequately. Immediate regular venous return flow with regular graft perfusion. Measurement of a size 3.5 coupler and insertion of the venous anastomosis with the coupler system. Subsequently, regular flow and excellent flap vitality. Subsequently, to protect against kinking, circumscribed suture fixation of the stalk course. Subsequent insertion of a guided 10 Redon drain and two-layer wound closure. Repositioning of the patient and completion of the procedure at this point without any indication of complications. The patient received intraoperative intravenous antibiotics with Unacid 3 g, which should be continued for at least 2 to 3 days postoperatively. Conclusion: Intraoperative R0-resected at least cT3 cN2b oropharyngeal carcinoma on the right with locally aggressive and extensive submucosal growth. Transcervical, complete removal of the basal tumor area. Postoperatively, please perform an X-ray gruel swallow on the 8th to 9th postoperative day with regular flap vitality. Due to the muscular deficit, prolonged swallowing rehabilitation is to be expected.