Initial consultation with the anesthesiologist. First pharyngoscopy and laryngoscopy: The described tumor is seen in the area of the palatal arch extending to the left side, just to the tonsillar lobe, on the right side transition to the tonsillar lobe or oropharyngeal side wall and growth caudally to the border to the base of the tongue. Inspection of the right vallecula again. No tumor here. Performing the PEG insertion: insertion of the esophagoscope into the stomach. After creating the diaphanoscopy, insertion of a 15 mm abdominal wall tube without complications. Fixation to the abdominal wall in the typical manner. Sterile dressing. Therefore now transoral tumor resection. The tumor is resected on all sides with a safety margin of 1-1.5 cm. The entire palatal arch, including the upper tonsillar lobe, the tonsillar lobe and parts of the oropharyngeal side wall on the right, including the wall in the deeper muscular area, are resected up to the base of the tongue, which is only resected at the edges, or up to the entrance of the hypopharynx. The specimen is removed and thread-marked, both at the edges of the mucosa and basally. In addition, a marginal sample is taken from the left in the area of the palatal arch and adjacent to the tonsillar lobe as well as caudally on the right at the border to the hypopharynx. Both the margins of the specimen and the edge samples are tumor-free. Thus R0 situation. Repositioning of the patient. Abjoding. Injection of a total of 10 ml Ultracaine 1% with adrenaline into both sides of the neck. Sterile draping of all relevant surgical areas. Start with the neck dissection on the right: skin incision curved in the typical manner. Exposure of the sternocleidomastoid muscle. Exposure of the digastric and omohyoid muscles. Detachment of the fat lymph node package from the sternocleidomastoid muscle. Exposure of the internal jugular vein, facial vein and external jugular vein. Exposure of the internal carotid artery, external carotid artery. Exposure of the superior thyroid artery, facial artery and lingual artery. Exposure, displacement and at the end of the operation re-embedding, in the sense of neurolysis, of the following nerves: hypoglossal nerve, vagus nerve, accessorius nerve and the branches of the cervical plexus. Overall clearing level II to V. Several definite or at least probably malignant lymph nodes cranially in level II to III. Careful irrigation and hemostasis. Transition to neck dissection on the left: This is performed in the same way as on the right side. Level II to IV evacuation is performed, exposing the structures also described on the right, as well as exposure, relocation and, at the end of the operation, re-embedding of the following nerves: hypoglossal nerve, vagus nerve, accessorius nerve and the branches of the cervical plexus. Then tracheostoma creation: small Kocher collar incision. Exposure of the subcutaneous tissue up to the infrahyoid musculature. This is split. The thyroid isthmus is passed underneath, clamped, severed and ligated using puncture ligatures. The trachea is then exposed. Exposure of a small, wide-stalked, modified Björ flap and epithelialization of the same. Re-intubation. Subsequent elevation of the radial flap: marking of the required flap dimension after measurement. Length 10.5 cm, maximum width 6- 6.5 cm. Mark the flap in the left forearm area with the central radial artery. First cut around the flap ulnarly, subfascially. Then extend the incision into the crook of the elbow. Exposure of the pedicle under the brachioradialis muscle. Exposure of the superficial venous system with connection between the superficial and deep venous system. Subsequent radial incision of the flap and subfascial detachment. Exposure of the lateral antebrachial cutaneous nerve. The radial artery is exposed caudally and initially clamped. After constant saturation between 95 and 100% for at least 15 minutes, the artery is severed and sutured proximally and distally using 4.0 Prolene stitches. The flap is then removed. Outgoing small vessels are treated bipolar or with clips. Dissection up to the crook of the elbow. Two outlets in the area of the cephalic vein and a smaller outlet in the area of the confluence can be dissected. Before exposing the radial artery, the interosseous artery is cut and clipped after prior clamping. The flap is then removed. Ligation in the area of the proximal venous stumps. The stump of the radial artery is treated at the entrance to the brachial artery by means of stitches above and below 6.0 Vascufil. Careful hemostasis and irrigation in the forearm area. Primary closure of the skin up to the defect. Defect is closed with split skin. This is removed from the thigh area using a dermatome and successively incorporated into the forearm defect. Subsequent application of Mepilex dressing, loose swab dressing. Wrapping with absorbent cotton. Fitting of a Cramer splint and wrapping with an elastic bandage. Attachment of the arm. Thigh area is treated with hydrocolloid dressing. After application, the hand always shows no signs of saturation and no signs of reduced circulation. Removal of the flap: After removal, the flap was already rinsed with heparin. Creation of a tunnel through the residual pharyngeal wall. This is at least 2 transverse fingers wide. Careful hemostasis here. Pass the stalk outwards into the soft tissues of the neck. The flap is sutured in successively, partly from the outside, through sutures placed in front, partly transorally. The defect can be completely closed without tension. The flap is sutured dorsally and ventrally to the remains of the palatal arch and folded. Then vascular anastomosis. Conditioning of the superior thyroid artery. This can be dissected quite close to the exit from the externa in the appropriate size. The arteries are anastomosed using 9.0 Ethilon single-button sutures. After opening the clamp, good arterial flow, good venous return. A portion of the facial vein and the external jugular vein are conditioned for the venous anastomosis. A branch of the cephalic vein is anastomosed with the external jugular vein using a coupler, post-conditioning of the veins. A 2.5 mm coupler is used. After opening the clamps, there is good venous flow. Positive smear phenomenon. The other outlet of the cephalic vein is then anastomosed with the outlet from the facial vein, also using a 2.5 m coupler after prior conditioning of the vessels. Good venous return here too, positive smear phenomenon. The small outlet in the confluence area is closed with two clips. Careful irrigation and hemostasis. The wound is closed by inserting two flaps on the right side, whereby the stalk shows a visible protrusion in the area of the middle of the skin suture. Nevertheless, marking of the site for Doppler control using Vicryl suture. The left side had already been closed in layers with the insertion of a Redon drain. Here, too, careful hemostasis and irrigation were performed beforehand. Application of a pressure bandage on the right and left. The tracheal cannula is then fixed with sutures. Intraoral inspection of the flap again. This is well supplied with blood. Completion of the procedure without complications. Final consultation with the anesthetist. The patient goes to the intensive care unit for monitoring. Please continue the intraoperative antibiotic treatment with Unacid for one week. Please carry out clinical checks and Doppler checks on vitality and blood flow in the radial lobe for 5 days. Heparin 500 units/hour was started intraoperatively and should be continued for a total of 5 days. Please feed for 7-10 days via the inserted PEG tube. Food build-up according to clinical findings, if necessary after swallowing porridge. After receiving the final histology, please attend the interdisciplinary tumor conference.