(<CLINICIAN_NAME>) Insertion of a tonsil plug and inspection of the tumor region. The tumor appears on both sides in the area of the soft palate, covers the uvula with the base of the uvula, but can be palpated rather superficially and then extends further down to the left tonsil lobe, covers the left tonsil and also passes macroscopically to the border of the upper pole of the tonsil on the right. Here, the mucosa is first cut around the soft palate with the monopolar needle. Then dissect with scissors and bipolar forceps. A safety distance of 1 ˝ to 2 cm is selected so that the entire soft palate must be removed in the mucosal area. The uvula is also removed, but the muscular tissue at the base of the uvula can be preserved. Further tumor resection in the area of the glossoalveolar groove and removal of the left tonsil. Then transition to the right side and removal of the right tonsil as well. The tumor specimen can be retrieved in its entirety and sent for histological examination marked with a thread. Then marginal samples are taken. The marginal samples are described as tumor-free except for the oropharyngeal side wall in the area of the glossoalveolar groove. There was still carcinoma in situ at this location, which is resected and can ultimately be designated as R0 in a frozen section margin sample. Neck dissection on both sides, initially starting on the left side. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle, the submandibular gland. Finding the accessorius nerve. Then exposure of the cervical vascular sheath and free preparation of the internal jugular vein. Level II shows clearly enlarged lymph nodes. Evacuation of level II, III, IV and V, sparing the plexus branches, the hypoglossal nerve, the border cord and the internal jugular vein, external and internal carotid artery, external jugular vein and superior thyroid artery. The facial artery was ligated. Then transition to neck dissection on the right side. In principle, the same procedure is used here. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle and the submandibular gland. Then visualization of the accessorius nerve. Exposure of the cervical vascular sheath and free preparation of the internal jugular vein. Evacuation of levels II, III, IV and V, sparing all structures. Then transition to tracheotomy. Skin incision just below the cricoid cartilage and dissection down to the thyroid gland. This is exposed in the isthmus area, undermined, clamped, severed and ligated. The trachea is then exposed. Entry between the 2nd and 3rd tracheal cartilage and creation of a visor tracheotomy without incision of a Björk flap and epithelialization of the skin in the sense of a mucocutaneous anastomosis. (<CLINICIAN_NAME>) After creating the R0 resection, the defect is now measured enorally. The defect extends from the hypopharyngeal entrance on the left over the entire soft palate to the hypopharyngeal entrance on the right. Defect length approx. 14 cm, width approx. 6 cm. A flap with dimensions of up to approx. 14.5 cm x 6 cm is made on the forearm. The tourniquet is then created. Now cut around the flap, initially from ulnar subfascial. Extension of the incision curved towards the crook of the elbow. Exposure of the superficial venous system, which is integrated into the pedicle. The flap is then recut from the radial subfascial side. Exposure of the radial artery. This is clamped off, severed and supplied using 4-0 Prolene puncture ligatures. Subfascial elevation of the flap along the vascular pedicle. Outgoing vessels are coagulated bipolar or treated with clips. The pedicle is exposed below the brachioradialis muscle and dissected out. Superficial venous system integrated into the pedicle. The connection between the superficial and deep venous system is exposed and preserved in the area of the crook of the elbow. Good confluence of the radial vein and good drainage via the cephalic vein is shown. The radial artery is visualized up to the entrance of the brachial artery. Then open the clamp, good reperfusion. Extensive hemostasis again. The flap is left on the perfusion until it is possible to suture it. The flap is then removed, the veins ligated and the brachial artery ligated using a 4-0 Prolene. Flap is flushed with heparin. The flap is then inserted into the defect. This is done successively with 3-0 single button sutures. Tension-free suturing under relatively difficult conditions with a relatively small mouth opening. The flap is sutured in correctly in three dimensions. A tunnel approx. 3 transverse fingers wide was previously created from the pharyngeal area into the left side of the neck. The vascular pedicle was passed through this. Conditioning of the vessels, initially the superior thyroid artery. This is first anastomosed to the conditioned radial artery using 9-0 Ethilon single button sutures. After opening the clamp, however, the pulse is insufficient. Open the suture. No more perfusion via the superior thyroid artery, no blood flow from the bulb even after extensive revision. Therefore now occlusion of the superior thyroid artery. Conditioning of the facial artery shortly after its exit from the external carotid artery. Anastomosis of the newly conditioned radial artery with the conditioned facial artery using 9-0 Ethilon single-button sutures. Here, after opening the clamp, good blood flow, good venous return. Then conditioning of the facial artery shortly before entering the internal jugular vein and suturing with the trimmed radial vein in the confluence area. This is done with a 2.5 mm coupler. The cephalic vein and the internal jugular vein are then conditioned. These are anastomosed using a 1.5 mm coupler. Good venous return after opening the venous clamps. Overall good flap perfusion. This is followed by configuration of the pedicle and suturing in the favored position. Subsequent extensive irrigation of the wound area and hemostasis. Wound closure on both sides of the neck after insertion of a Redon drain, which is guided on the left. Skin closure also takes place with epithelialization of the tracheostoma. The forearm defect is closed using skin from the groin on the right. For this purpose, a piece of full-thickness skin is removed from the groin in the typical manner, according to the dimensions. After mobilization of the skin, the groin is closed in several layers with the insertion of a Redon drain. Low-tension closure. After thinning, the full-thickness skin is sutured into the forearm defect without tension. Hydrogel-Mepilex dressing is applied over this. Loose swabs are placed on top and the arm is wrapped in absorbent cotton. Fitting of a Kramer splint and fixation of the arm to the Kramer splint with an elastic bandage. Forearm always well perfused. Finally, insertion of an 8 mm tracheal cannula, which is fixed with sutures. Skin disinfection. No dressing except for plaster at the incision site. Patient goes to the intensive care unit for postoperative monitoring. Antibiotic treatment with Unacid, as started intraoperatively, should be continued for 2 to 3 days in total. Feeding via the inserted PEG tube for 10 days, then if necessary, diet build-up. Flap control clinically and via Doppler probe at the mark on the left side of the neck according to the usual postoperative scheme for 5 days. Please continue heparin perfusor 500 units per hour for 5 days. Patient should be elevated 30° and ventilated for 1 night postoperatively. Overall extensive, relatively flat growing oropharyngeal carcinoma cN2c cT3 to 4. Postoperatively, according to the histology, discuss radiotherapy vs. radiochemotherapy.  