First, pharyngoscopy and MLE again: The exophytic tumor is visible, which starts at the palatal arch next to the uvula on the left, extends over the tonsillar lobe to the base of the tongue. In the area of the pharyngeal side wall up to the edge of the posterior wall. The tumor shows exulcerative character and deep growth. Therefore primary indication for combined resection. Sterile draping and injection of a total of 20 ml Ultracaine 1% with adrenaline in the area of both sides of the neck. Start with transoral resection: Cut around the tumor with a safety margin of 1 ˝ to 2 cm on all sides, initially from the enoral side. Smaller parts of the palatal arch on the right, the uvula, the entire palatal arch on the left, mucosa along the alveolar ridge up to the glossoalveolar groove and the beginning of the tongue base, pharyngeal posterior wall falls to the middle, caudally the resection extends from the transoral side to the entrance of the piriform sinus. Then repositioning for neck dissection on the right with subsequent completion of the resection from transcervical: submandibular incision. Cut along the sternocleidomastoid muscle caudally. Exposure of the sternocleidomastoid muscle. Showing digastric muscle, submandibular gland. Showing the omohyoid muscle. Exposure of the cervical vascular sheath, internal jugular vein, external and internal carotid artery. Exposure of the hypoglossal nerve, vagus nerve and accessorius nerve. Successive evacuation level I b to V. Co-resection of the submandibular gland. Exposure and preservation of the superior thyroid artery. The facial artery is ligated cranially in preparation for tumor resection. The transoral resection is then completed by transcervical resection: the entire pharyngeal wall is included up to the cervical vascular sheath. A portion of the base of the tongue is resected caudally as well as the mucosa up to the piriform sinus entrance and all soft tissue up to the cornu superius or hyoid bone. In total, marginal samples are taken from the palatal arch, laterally to the alveolar ridge, from the area of the posterior pharyngeal wall. In addition, a cranial basal margin sample and a caudal basal margin sample are taken. All marginal samples are sent to frozen section diagnostics with the tumor specimen, which is marked with a thread. In the frozen section, all margin samples are tumor-free, as is the specimen. Thus R0 situation intraoperatively. Subsequent left neck dissection and tracheotomy (<CLINICIAN_NAME>). Neck dissection left: Skin incision. Then exposure of the anterior edge of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Exposure of the submandibular gland and digastric muscle. Visualization of the cervical vascular sheath. Level II shows several lymph node metastases, which are removed while sparing the vessels of the jugular vein, the external and internal carotid arteries and while sparing and exposing the hypoglossal nerve, vagus nerve and accessorius nerve. Then further successive evacuation of levels I, III and V. Exposure and preservation of the superior thyroid artery and facial artery. Then repositioning for tracheotomy. Skin incision in the usual manner. Dissection of the musculature. Push the muscles to the side and expose the thyroid gland. Undermining of the thyroid gland and clamping on both sides. Then transection of the isthmus and ligation on both sides. Exposure of the trachea. Opening of the trachea between the 2nd and 3rd tracheal cartilage gap. Omission of a Björk flap and epithelialization of the skin. Insertion of a laryngectomy tube, which was later intubated with a tracheal cannula. The radial flap is then removed: first the size and dimensions of the flap are measured at the situs. Maximum length 14 cm, maximum width 9 cm. The size and dimensions of the flap are marked on the forearm. Flap elevation is performed without tourniquet. Saturation at the beginning 100%. Cut around the flap first from the ulnar, then from the radial side. Extension of the incision curved in the direction of the crook of the elbow. Subfascial elevation of the flap successively. Exposure of the flap pedicle below the brachioradialis. Previously, the superficial venous outflow was also exposed above it. The radial artery was visualized and clamped for 20 minutes. There was no deterioration in saturation, which was always 100%. Subsequently, the radial artery was removed and treated with 4-0 Prolene stitches caudally and cranially. Flap is successively lifted subfascially, smaller vessels are coagulated bipolarly or supplied with clips. Lifting of the flap pedicle up to the elbow. Exposure of the radial artery, brachial artery, ulnar artery and interosseous artery. Also show the radial vein and the superficial venous outflow, which ends in 2 branches in the area of the cephalic vein. There is a stable connection to the deep venous system. Subsequent removal of the flap, ligation of the veins, removal of the radial artery before the interosseous outlet. Here clip and stitch sutures with 4-0 Prolene. Flap is irrigated with heparin. Subsequent insertion of the flap into the defect: The flap is inserted into the defect according to the size and shape lifted. The flap pedicle is inserted caudally below the preserved hypoglossal nerve on the left and passed through a previously created tunnel to the right side. Successive suturing of the flap, partly with sutures in the defect. Tension-free, anatomically correct suturing is achieved. Subsequent anastomosis of the vessels on the right side: conditioning of the radial artery and the superior thyroid artery. These are sutured using 8-0 Ethilon single-button sutures. After opening the clamps, good arterial flow and very good venous return. Subsequent conditioning of the radial vein and cephalic vein. Also conditioning of a small outlet from the facial vein and the external jugular vein. The smaller radial vein is anastomosed to the outlet from the facial vein using a 1.5 mm coupler. The cephalic vein is also anastomosed with the external jugular vein using a second coupler size 3.5 mm. Good venous return in each case. Positive smear phenomenon. Flap very well perfused intraoperatively. Subsequent irrigation of the wound area, careful hemostasis. Layered wound closure with insertion of a Redon drain in each case. The position of the anastomosis in the area of the external jugular vein is marked. Then insertion of an 8 mm tracheal cannula, which is fixed with sutures. Defect coverage of the forearm using inguinal skin from the right: An appropriately sized piece of full-thickness skin is removed from the groin area in the typical manner. The inguinal skin is mobilized accordingly and then closed in several layers with the insertion of a Redon drain. Skin sutures using the Donati technique. Full-thickness skin is then thinned out and successively sutured into the defect on the caudal forearm. This is done without tension. The upper sections of the wound on the forearm are closed in layers in the typical manner. A hydrogel-Mepilex dressing is then applied, followed by a loose compress dressing and wrapping in absorbent cotton. Fitting of a Kramer splint and wrapping in an elastic bandage. The procedure is completed without complications. Patient goes to the intensive care unit for postoperative monitoring. Please continue antibiotics, which were started preoperatively, for a total of 1 week. Heparin perfusor 500 units per hour for 5 days. Flap control in typical clinical manner and by means of Doppler control for 5 days. Total cT3 cN2c oropharyngeal carcinoma on the left. R0 resection intraoperatively. Postoperatively, due to the overall situation, RCT to be discussed. Feeding via a PEG tube for 10 days, then control of swallowing of gruel and diet build-up.