First perform a pharyngoscopy. Insertion of the open mouth retractors. An exophytic tumor can be seen in the area of the anterior palatal arch, sitting on the ascending mandibular branch, coarsely caked here and rather difficult to move. Growth to parauvular. The tonsillar lodge is used up, also clear infiltration of the posterior palatal arch. Growth continues over the glossotonsillar groove into the edge of the tongue, which is also circumscribed towards the posterior floor of the mouth and extends to approx. 3 cm in the area of the edge of the tongue as well as clear infiltration of the base of the tongue to approx. 1/4. Caudally in the area of the pharyngeal side wall, the tumor extends caudally to about the level of the oropharyngeal border. Epiglottis, vallecula and supraglottic region are free. The posterior wall of the oropharynx is also free. Now resection of the tumor transorally with the electric knife and using the dissection technique. Resection hard to parauvular while maintaining a safety margin of at least 1-1.5 cm. Removal of the entire anterior palatal arch, resection up to the buccal. Resection of the posterior palatal arch en bloc, in the area of the ascending mandibular branch here periosteal growth, but no infiltration. Infiltration of medial pterygoid muscles, therefore now exposure of the mandibular bone in the area of the ascending mandibular branch, pushing off the periosteum here with the raspatory. Resection of the posterior floor of the mouth and the edge of the tongue. Here too, maintaining a safety margin of at least 1 to 1.5 cm on all sides. Resection up to the base of the tongue and, in the case of resection in the area of the posterior floor of the mouth, exposure of the submandibular gland enorally after detachment of the tumor from the posterior pharyngeal wall. After complete detachment, the tumor is now left in the area of the posterior floor of the mouth and the base of the tongue, and the decision is made to proceed transcervically with better local control. Later, the parts of the lower jaw close to the tumor are also trimmed with the rose bur. Covering samples are now taken from the edges of the tongue, the posterior floor of the mouth, the soft palate and the buccal mucosa. These are assessed as completely tumor-free in the frozen section diagnostics. Now repositioning and turning to the neck dissection with tumor resection on the right side. Skin incision on the anterior edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Exposure and preservation of the external jugular vein and the auricularis magnus nerve. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle, exposure of the digastric muscle and the submandibular gland. Exposure and free dissection of the internal jugular vein, careful dissection here. A clearly caked lymph node conglomerate can now be seen in the area of the venofacial angle. The facial vein itself is only very weakly developed and must be removed in the area of the metastases. Otherwise, there are no other internal jugular veins. The jugular vein is not infiltrated after careful dissection. Clearing of the anterior neck preparation with careful protection of the superior thyroid artery. Expose the hypoglossal nerve. Now expose the accessorius nerve. Clearing of the accessorius triangle with careful protection of the nerve and clearing of level Vb with careful protection of the cervical plexus branches. Subcapsular release of the submandibular gland. Resection of the digastric muscle, subtotal removal of the gland and thus performance of the pharyngotomy. The pharyngotomy is opened in the anterior region of the resection margins. Now reopen the mouth retractor and perform a combined resection towards the base of the tongue caudally to the vallecula and from the outside to the level of the hyoid. The tongue base resection is now separated from the cranial oropharyngeal resection for a better overview. Now turn back to the neck. It quickly becomes apparent that all branches of the external carotid artery and the cranial thyroid artery lead to the tumor. The facial and lingual arteries are therefore ligated, as is the maxillary artery. The internal carotid artery is now separated together with the vagus nerve from the superior pharyngeal constrictor muscle up to the level of the styloid process and thus safely spared. Using the styloid process as a landmark, the entire lateral pharyngeal musculature is resected from caudal to cranial up to the posterior pharyngeal wall. Now repeat the procedure enorally. The styloid process can also be identified here and serve as a guide for the resection. In the end, a 5 cm resectate is created. Due to the large wound area, 3 separate marginal samples are taken from the wound bed. In addition to the posterior pharyngeal wall central margin sample and the vallecula and hyoid margin samples. These are later all assessed as tumor-free. Therefore, an intraoperative R0 resection can be assumed here. Finally, as described above, the areas of growth close to the periosteum in the area of the ascending alveolar ridge are removed with the drill. Moderate connection conditions now remain on the right side in the area of the right external jugular vein and the remaining superior thyroid artery. Therefore, after previously measuring a graft adapted for the soft palate, tongue, tongue edge and floor of the mouth with a total area of 11 x 8 cm, a radial graft is lifted with special consideration of the posterior floor of the mouth and the edge of the tongue with the possibility of bilateral connection. Therefore, the radial flap is now lifted in parallel. Unwrap the arm and apply the tourniquet. After marking the graft, cut around the graft. Exposure and securing of the cephalic vein. Perform the same maneuver and expose the radial superficial ramus nerve. These can be completely spared. Exposure of the brachioradialis muscle and the cephalic vein. A skin monitor is not used in the course of potential bilateral anastomosis. Exposure of the radial veins, these are relatively slender distally. Blunt exposure Ligation of the distal vascular pedicle. Release of the distal vascular pedicle. Now strictly subfascial dissection. Further release of the graft. Circumscribed visible ulnar artery, but no further dissection and safe protection. Now complete subfascial elevation of the graft, exposing a cancerous bridge between the radial vein and cephalic vein in the area of the crook of the elbow. Salvage of this bridge, clipping of outgoing venous branches. Exposure of the radial artery before the exit of the very strong and significantly larger ulnar artery; a true anterior interosseous artery is not found here. Marking of the artery and reopening of the tourniquet. After a total of 90 minutes, minute hemostasis, regular flap perfusion and preparation for subsequent flap elevation. After graft displacement, an 11 x 8 cm piece of full-thickness skin is removed from the groin. In the groin area, after strict cutaneous elevation, subcutaneous mobilization and, if the wound is dry, placement of a 10-gauge Redon drainage and careful, strong, two-layer wound closure and later incorporation of the full-thickness skin graft and here, after careful wound inspection, two-layer wound closure. Complete incorporation of the full-thickness skin graft in this case with a complex flap, therefore somewhat more difficult incorporation conditions, but finally sufficient closure, application of a vacuum seal and application of the Kramer splint in the usual manner. At the same time, the neck dissection was performed on the left side. To do this, also make a skin incision on the anterior edge of the sternocleidomastoid muscle, cut through the skin and subcutaneous tissue. Separation of the playtsma. Creation of a platysma flap, exposure of the external jugular vein, which is very narrow here, and the auricular nerve. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Exposure of the submandibular gland and the digastric muscle. Exposure of the anterior neck preparation with careful protection of the cervical artery and the very slender superior thyroid artery. Exposure and preservation of the hypoglossal nerve. Exposure and free preparation of the internal jugular vein. A macroscopically conspicuous lymph node measuring approx. 2 x 1.5 cm without infiltration of neighboring structures can be seen in the area of the jugulofacial angle. V. facialis is relatively weakly developed here, but is preserved. Exposure of the accessorius nerve. Careful release of the accessorius triangle with careful protection of the nerve and release of level V with careful protection of the cervical plexus branches. Finally, dry wound conditions and no evidence of lymph leakage in level V. After wound irrigation with Ringer's solution, insertion of a 10-gauge Redon drain and careful two-layer wound closure with primary graft connection attempt on the right side. Now perform a plastic tracheotomy. To do this, make a horizontal skin incision sparingly to avoid a possible connection to the cervical resection areas. Cut through skin and subcutaneous tissue. Cut through the infrahyoid muscles. Exposure of the cricoid cartilage, exposure of the anterior surface of the trachea. Bipolar coagulation of the very thin thyroid isthmus. Further exposure of the anterior surface of the trachea. Insertion between the 1st and 2nd tracheal ring: creation of a broad-based pedunculated Björk flap. Incision of the tracheostoma with mucocutaneous anastomosis and subsequent problem-free intubation onto an LE tube. Later reintubation onto an 8-gauge cannula with inner core, which is fixed by suturing. Now, after recovery of the graft, incorporation of the graft transenorally. In this case, with significant tongue swelling and edematous conditions, relatively difficult insertion conditions. Laborious reconstruction of the soft palate and suturing in the area of the cheek soft tissue, the posterior floor of the mouth and the edge of the tongue. Overall, however, a good fit. Finally, transcervical suturing of the base of the tongue and the lateral pharyngeal wall. Finally, tight conditions and sufficient flap detachment. Now condition the vessels by free preparation of the cubital subcutaneous veins carried out in the evening. Now a good opportunity for adequate pedicle positioning. Careful fixation of the pedicle peripherally with Vicryl sutures. Separation of the superior thyroid artery after peripheral clipping. Here after opening good flow. Conditioning of the vessels and anastomosis with 8.8 Ethilon in relatively equal caliber conditions. This is initially successful. However, there is now a marked vulnerability in the area of both vessels. There are several tears in the vessels, so that a stable and tight anastomosis cannot be achieved despite several attempts at suturing. Therefore excision of the anastomosis. The flap artery and the superior thyroid artery are shortened and a new vascular anastomosis is performed. This is successful despite difficult suture conditions. Immediate regular venous return with good flap perfusion. Venous return is strong, but only via one of the two elevated cubital veins. Therefore clipping of the 2nd vein. Conditioning of the external jugular vein, which is thrombosed in the meantime, therefore shortening of the vein. Free preparation continued, irrigation with heparin. Finally, good flow and clear conditions. After removal of a thrombus, careful irrigation and sizing of a 2.5 mm coupler and subsequent problem-free venous anastomosis with the coupler. A well-positioned pedicle with relatively stable conditions and excellent flap perfusion enorally is now evident, so that careful two-layer wound closure with a caudally extended flap is now performed and the procedure is completed at this point. Conclusion: Due to the intraoperative extension cT3 cN2c oropharyngeal carcinoma on the right with R0 situation macroscopically and in the frozen section diagnosis. The patient received intraoperative intravenous antibiotics with Unacid 3 c. Postoperative regular enoral flap vitality control in the absence of a skin monitor. Due to the venous anastomosis located directly subcutaneously on the right side at the anterior edge of the sternocleidomastoid muscle, strict attention must be paid to avoiding pressure bandages or similar. Depending on the endoscopy findings, diet build-up and, if necessary, decannulation are possible from the 8th postoperative day.