This is followed by bronchoscopic intubation by the anesthesia colleagues. Followed by pharyngoscopy again: once again, the small bore tube size C and D is used. Although the tumor can be visualized, its extent is barely detectable with the small bore tube. This once again confirms the indication for an external approach. This is followed by repositioning, injection of a total of 20 ml xylocaine 1% with adrenaline in the area of both sides of the neck and sterile draping. Start with modified apron flaps: The right apron flap is lifted in a typical manner, slightly widened caudally on the left, in order to also develop a platysmal flap from this to cover the defect in the tongue base area if necessary. The flap is elevated to the level of the hyoid bone or the submandibular gland. Neck dissection on the left side: exposure of the sternocleidomastoid muscle anterior border. Dissection of lymph node fat packet. Exposure of the cervical vascular sheath, internal jugular vein, internal/external carotid artery. Exposure of vagus nerve, accessorius nerve. Development of the dorsal neck preparation with exposure and preservation of the branches of the cervical plexus. Then develop the anterior neck preparation, exposing and preserving the superior thyroid artery and the hypoglossal nerve. Exposure and preservation of the cervical artery. This results in an evacuation of levels II to V on the left. Neck dissection on the right side: This is performed in the same way as on the left side, exposing the structures mentioned, which are also preserved. Level II to IV removal is performed here, followed by transcervical tumor resection: exposure and skeletonization of the hyoid bone. The pre-epiglottic fatty tissue is completely removed behind the hyoid bone. This is also removed from the right to the left of the epiglottis and integrated into the tumor preparation. Right paramedian entry into the larynx at the level of the epiglottis. The tumor can now be visualized, viewed with relative difficulty and successively removed by means of inspection and palpation. Tumor is incised on all sides with a safety margin of 1 to 1.5 cm and removed in toto. Two thirds of the epiglottis is freed from the lingual mucosa. The left pharyngeal wall is removed, the base of the tongue is removed by about two thirds, whereby the resection to the right is not too deep, so that the lingualis can be spared here. Resection extends in the area of the pharyngeal wall to just before the tonsil lobe. Tumor is removed and marked with a suture. Due to the relative proximity caudally in the area of the epiglottis, a strip of mucosa is removed from the epiglottis area, which corresponds to the rest of the epiglottis mucosa lingually. The tumor is removed in the frozen section towards all edges in the healthy area, but small focal in-situ infiltrations are still visible in the area of the mucosa sample of the remainder of the lingual epiglottis. Therefore, the tip of the epiglottis is removed, the left third and a thick strip of mucosa in the direction of the arytenoid fold and pharyngeal wall. This preparation is thread-marked and sent for frozen section examination, whereby the side remote from the tumor is marked. There are no more infiltrates here, so that an R0 resection can now be assumed. This results in a defect of two thirds of the tongue base mucosa area, the pharyngeal wall on the left, from the tonsil lobe to the hypopharyngeal entrance and supraglottic on the left including the aryepiglottic fold. The three-dimensional shape of the defect is measured. The radial flap is now elevated: Flap size is drawn in according to the three-dimensional requirements. The skin monitor is also drawn in. Then angle the arm and apply a tourniquet. Gradually develop the radial artery flap from subfascial, taking subcutaneous tissue with it, if necessary for the skin monitor. The radial artery is placed caudally and supplied proximally and distally using 4.0 Prolene puncture ligatures. Outgoing smaller vessels to the muscles are supplied with clips. Confluence of the radial vein, radial artery and cephalic artery can be exposed in the elbow area. A running cutaneous nerve can also be dissected and lifted along with the flap. After opening the tourniquet, good perfusion of the flap and the skin monitor. Deposition of the flap, whereby the outlet of the radial artery is treated with a 4.0 Prolene stitch. Veins are ligated. Flap vessels are flushed with heparin and placed in saline compresses. The flap is then sutured into the defect: Once the flap has been placed in the correct position, it is sutured successively using 3.0 Vicryl single-button sutures. Tension-free suturing with complete closure. Flap handle is passed through from left to right. The flap is connected in an end-to-end anastomosis between the radial artery and the superior thyroid artery using 9.0 Ethilon single-button sutures. After releasing the clamp, good perfusion and good venous return. The flap vein and facial vein are then conditioned. After measuring the vascular lumen, the anastomosis is performed without complications using a 3 mm vascular coupler. After opening the clamps, good reflux, positive smear phenomenon. Overall good perfusion of the flap. Co-prepared cutaneous nerve is now adapted on the left side to the stump of the superior laryngeal nerve, which had to be sacrificed during tumor resection, using several Ethilon 9.0 sutures to sensitize the radial lobe. Subsequent tracheostoma creation: splitting of the thyroid isthmus and coagulation. This is very thin and rudimentary. Visualization of the anterior tracheal wall. Entering the 2nd/3rd intercartilaginous space and creation of a broadly pedicled Björk flap. Epithelialization of this. Re-intubation and insertion of a 9 mm tracheal cannula. This is followed by irrigation of the wound area with H2O2 and Ringer's solution, as directly after the tumor resection, as well as at the end of the entire operation, and careful hemostasis. Insertion of a Redon drain into each side. Repositioning of the apron flap. Skin incision at the level of the skin monitor and insertion of the skin monitor. This is fixed in the skin without tension using subcutaneous sutures and skin sutures. The wound is then closed in layers in the area of the apron flap and the epithelialization of the tracheostoma. Full-thickness skin removal from the groin: Depending on the size of the defect, a piece of skin, approx. 8 x 6 cm, is harvested from the groin as a full-thickness skin graft. This is thinned out. In the groin area, after mobilization of the skin, the wound is closed in layers and a Redon drain is inserted with minimal tension. After thinning, the removed full-thickness skin is sutured into the area of the forearm defect without tension. The forearm is closed in layers. A sterile Vacuseal dressing is then applied, which works with a suction of 75 mmHg. The arm is then wrapped in a Kramer splint using an elastic bandage. Then mark the localization for vascular control with the Doppler. The cannula is fixed with tape. Completion of the procedure without complications. Patient received Unacid intraoperatively as an antibiotic. Please continue postoperatively for 1 week. Heparin at 500 units per hour, as started intraoperatively, continue for 5 days postoperatively. Feeding via the previously inserted PEG tube for approx. 10 days, then gruel swallow and swallowing attempt, if necessary diet build-up, but intensive swallowing training is certainly necessary here. Please contact the voice and speech department or speech therapist at an early stage. Overall cT2-3 cN2b oropharyngeal carcinoma on the left, postoperative RT or RCT to be discussed after histological findings.