First deepening of the anesthesia. After intubation through the anesthesia, pharyngoscopy and confirmation of an oropharyngeal carcinoma measuring at least cT2 on the left side, which just reaches the posterior wall of the oropharynx and extends caudally and medially into the base of the tongue. On palpation, the tumor is slightly larger in comparison with the computer tomography and is difficult to move laterally. Initially under strict diaphanoscopic control and after administration of 3 g Unacid, after skin disinfection and abjodation, placement of a 15 Charričre PEG tube using the thread pull-through technique. Strict diaphanoscopic conditions on all sides. The gastric mucosa is unremarkable. Sterile dressing. Then insertion of the tonsil plug. Inspection of the tumor tissue again. Then, using the electric needle of the bipolar forceps under visualization, start resection of the tumour from cranial to caudal, taking parts of the base of the tongue with it. The tumor is not visible at any time and is released at a wide macroscopic distance. However, it becomes apparent that the tumor has grown laterally into the pterygoid musculature and the palpatory distance of the lateral tumor border lies in depth up to the immediate vicinity of the carotid flow area. It was therefore decided to continue the tumor resection transcervically; 2 cranial margin samples were tumor-free. Skin disinfection and infiltration anesthesia with a total of 18 ml Ultracaine with added adrenaline on both cervical and median sides. Start with neck dissection on the left side: skin incision on the anterior edge of the sternocleidomastoid. Dissection of a subplatysmal portion of connective tissue. Release of the connective tissue sheath ventrally. Identification of the internal jugular vein, the omohyoid muscle and the digastric muscle. Remove the entire soft tissue mantle from the medial neck preparation, identify the superior thyroid artery and the hypoglossal nerve. Now release from caudal to cranial. Dissection of the internal jugular vein, the vagus nerve and the cervical nerve. Level III and II show large, conglomerate-like lymph node metastases through which the accessorius nerve runs. It was therefore decided to resect the nerve. The internal jugular vein, which also runs through the metastasis, is then removed together with the metastatic conglomerate. The external jugular vein is preserved. After releasing and removing the submandibular gland, access is gained through level I b into the oropharynx. The en bloc resection of the tumor is now completed. Basally in the wound area to the lateral side, the pathology still describes an R1 situation, which is why selective resection is performed again at this point; the other marginal samples were tumor-free. Dissection of the external and internal carotid artery. Ligation of the left lingual artery. Identification of the vascular nerve bundle of the superior pharyngeal artery. Subtle hemostasis and neck dissection on the right side: Here too, 2 to 3 oval lymph nodes are visible in levels II and III, but overall they are also to be classified as suspicious. Neck dissection levels I b, II, III and IV and partial V are now performed. The submandibular gland is preserved, as are the external jugular vein, vagus nerve, cervical nerve, accessorius and hypoglossus. The internal jugular vein is also preserved on this side; the submandibular gland, removal of 2 inconspicuous lymph nodes from level I b. After a door-like incision, cut the cutaneous and subcutaneous tissue to create a plastic tracheotomy. Blunt separation of the infrahyoid musculature. Identification of the anterior tracheal surface after transection of the isthmus of the thyroid gland. Visualization of the anterior surface of the trachea caudally. Incision between the 2nd and 3rd tracheal clasp area. Formation of a Björk flap. Re-intubation. After ethibond suture fixation at 6 points on a 9 mm Rügheimer cannula and problem-free ventilation. Suture fixation of the cannula edges with an Ethibond suture. Then removal of an area of inguinal skin measuring 12 x 6 cm and placement of a Redon drain. At the same time, the radial flap on the left side of the forearm is removed. After placing the tourniquet, the oropharyngeal defect region is marked. This is now adapted to the forearm. Skin incision, cut in an S-shape, from the crook of the elbow into the flap area. Starting radially, detachment of the myofascial tissue portion, release of the flap with identification of the antebrachial cutaneous nerve and the parallel vein. Identification of the radial artery-venous bundle and consecutive release from distal to proximal with multiple clip ligation and bipolar coagulation of the draining and feeding branches. It is thus possible to develop a wide stalk which, however, consists of 2 small caliber veins. Removal of the tourniquet and further hemostasis and preparation of the left cervical vascular area. Removal of the pedicle and primary closure of the defect with the inguinally removed full-thickness skin and application of a VAC dressing. Please leave this in place for 7 days. Suture removal on the 7th day. Please take photo documentation, several times intraoperatively. Then also dissect the stalk of the arterio-venous vascular bundle. Now primary suture of the artery or connection to the superior thyroid artery using 8.0 Ethilon. After dissection, the external jugular vein is first recruited and supplied with a 2.0 mm coupler. The second vein is supplied with a 1.0 coupler from a venous vessel in the area of the superior or middle thyroid vein. Overall, this is very difficult to achieve, but a dense vascular anastomosis is created in both the arterial and venous areas. After placement of a Redon drain on both cervical sides, the wound is closed in two layers and a dressing is applied. Discrete signs of congestion enorally at the end of the operation but good perfusion. Cannula change on day 3 to 5; suture removal on the neck on day 7.  