After induction of anesthesia and intubation by the anesthesia colleagues, a tracheostomy is performed first. Initial sterile washing and draping of the neck area. Marking of the skin incision for the tracheotomy, where the apron flap will later be made. Skin incision, then exposure of the infrahyoid muscles. Pushing aside the infrahyoid musculature. Exposure of the thyroid isthmus. Dissection of the thyroid isthmus. Exposure of the anterior wall of the trachea and insertion between the 2nd and 3rd tracheal cartilage and creation of a visor tracheotomy. Then insertion with the small bore tube and inspection of the hypopharyngeal and laryngeal area. On the left side of the hypopharynx at the entrance to the piriform sinus on the lateral and anterior wall, an exophytic, coarse mass can be seen. This mass is not easy to move and infiltrates the entire pharyngeal wall. Laser resection is therefore not possible. Then sterile washing and draping and creation of an apron flap in the usual manner. Then work in parallel with neck dissection on the right and neck dissection on the left. Neck dissection on the left by <CLINICIAN_NAME>: Incision of the skin and subcutaneous fatty tissue in a skin fold on the anterior edge of the sternocleidomastoid muscle at least 2 transverse fingers below the lower jaw. Separation of the platysma and identification of the sternocleidomastoid muscle. In the case of previous surgery (neck dissection), extremely scarred conditions with difficult dissection and identification of the surrounding structures. Identification of the internal jugular vein. This is firmly fused to the sternocleidomastoid muscle and can be separated from the muscle with careful dissection. Identification of the common carotid artery and the vagus nerve. Identification of the carotid bifurcation and visualization of the superior thyroid artery and the facial artery. Identification of the accessor nerve in a scar bed and release of the nerve. Dissection down to the deep cervical fascia and the cervical plexus. The mass in level V described in the ultrasound and CT can be identified in depth and is removed. Completion of the neck dissection/node picking without complications. Neck dissection on the right by <CLINICIAN_NAME>. Dissection of the sternocleidomastoid muscle and the omohyoid and digastric muscles. Exposure of the cervical vascular sheath. In very heavily scarred conditions, the internal jugular vein is torn several times. However, this can be sutured again with Vascufil 6-0 so that the blood flow is completely preserved. The accessorius nerve and hypoglossal nerve are then exposed and isolated lymph nodes and fatty material are removed. However, the neck is largely free of lymph nodes and fatty tissue due to the previous operation, so that no really large neck preparation remains. Then dissection of the facial vein, which has several outlets, and dissection of the superior thyroid artery as the arterial connecting vessel. Then lifting of the radialis graft by <CLINICIAN_NAME> and <CLINICIAN_NAME> parallel to the tumor resection. Tumor resection through <CLINICIAN_NAME> on the left side. For this purpose, the small bore tube is again inserted into the pharynx via the mouth and the height of the pharyngotomy is determined. Start with the pharyngotomy on the lateral side of the pharynx on the left. Exposure of the tumor. Then cut around the tumor with a safety margin of 1.5 cm. As it is not certain whether the tumor will infiltrate the thyroid cartilage towards the basal edge, part of the thyroid cartilage is resected at the same site. The tumor is placed completely on cork and a frozen section is made. The frozen section shows that all edges are tumor-free. Then measurement of the defect and suturing of the graft by <CLINICIAN_NAME>. Elevation of the radial forearm flap on the left by <CLINICIAN_NAME>: Palpatory identification of the distal radial artery. Marking of the flap borders (6 x 11 cm) on the distal forearm, proximal to the flexor retinaculum, with an S-shaped incision running proximally into the cubital fossa. Incision of cutaneous and subcutaneous tissue starting proximally. Identification and visualization of the venous confluence in the cubital fossa. Identification of the cephalic vein and dissection of the vein distally with integration into the radial graft margin. Identification of the ramus externus of the radial nerve and elevation of the radial portion, leaving the peritendineum of the tendons of the brachioradialis muscle intact. Subsequent ulnar incision down to the forearm fascia. Incision of the fascia and subsequent subfascial elevation of the ulnar edge of the graft up to the tendon of the flexor carpi radialis muscle. Care is taken to leave the peritendineum on the flexor tendons and to spare the ulnar artery. Identification of the distal radial artery and trial clamping with a vascular clamp. After 5 minutes with good oxygen saturation measured by pulse oximetry (measured on the index finger), the vessels are removed with subsequent ligation (Prolene 6.0). Successive detachment of the flap pedicle from the M. pronator quadratus and M. flexor pollicis longus with ligation of the outgoing perforators using a vessel clip into the cubital fossa. Exposure and protection of the radial nerve on the medial side of the brachioradialis muscle. Exposure of the brachial artery, V. mediana cubiti, A. ulnaris. First removal of the radial artery, then of two veins of the superficial venous system. Vascular ligation by means of a bypass ligature (artery) and vascular clip (veins). Subtle hemostasis in the area of the wound bed using bipolar coagulation forceps. Two-layer wound closure in the area of the proximal forearm. Covering of the graft bed with split skin from the right thigh in the usual manner. Suturing of preparation swabs. Application of a wound dressing and a forearm splint. Completion of the graft lift without complications. After removal of the radial flap, it is flushed with heparin. Vascular preparation of the cervical right side. The facial vein can be dissected as a venous connecting vessel, and the external jugular vein can also be used. The superior thyroid artery is selected as the arterial connecting vessel. First insert the flap into the defect and suture it in successively using 3-0 Vicryl single-button sutures. This is achieved with little tension and in an anatomically correct manner. The pedicle is now passed over the soft tissue to the opposite side on the right. The facial vein is then placed as cranially as possible and ligated cranially. Then also clamp the superior thyroid artery. This is double-clipped distally and removed and flushed with heparin, as is the facial vein. Conditioning of the superior thyroid artery and the radial artery. Subsequent suture or anastomosis with 9-0 Ethilon single-button sutures. Here, after opening the clamp, good arterial flow and good venous return. Then conditioning of the veins. The confluence shows very good venous return and is selected for the anastomosis with the facial vein. After conditioning the vein, the anastomosis is created using a 3-coupler. After opening the clamps, good venous return, positive smear phenomenon. The slightly longer cephalic vein, which is also thinner, should be anastomosed with the external jugular vein. To do this, the external jugular vein must be dissected further caudally and mobilized until it enters the deeper venous systems. It is then passed under the sternocleidomastoid muscle, which is partially severed at the corresponding point and thus thinned out to avoid compression. The vein can then be passed through the internal jugular vein without any problems. Anastomosis with the cephalic vein is now possible without tension. This is done after conditioning the veins with 2.0 Coupler. After opening the clamps, there is also good venous return, positive smear phenomenon. Another smaller venous outlet in the pedicle area is then clipped. Extensive irrigation of the wound area, careful hemostasis. The apron flap is then fixed to the upper edge of the tracheostoma with Ethilon sutures. The skin monitor, which now runs underneath the apron flap, is marked at its position, incision is made at exactly this point from the outside through the skin and the skin monitor is passed through. This is then loosely fixed with 5-0 Ethilon single button sutures. Good blood circulation here. Then successive closure of the wound on both sides, on the right with insertion of a Redon drainage, on the left with insertion of 2 flaps and epithelialization of the tracheostoma. An 8-gauge tracheostomy tube was then inserted and secured with sutures. On final inspection, the skin monitor is well perfused. The procedure is completed without complications. The patient is ventilated and admitted to the intensive care unit. Postoperative continuation of antibiotics with Unacid for 1 week. Feeding via the inserted PEG tube for at least 10 days, then gruel swallowing and, if necessary, diet build-up or presentation to the voice and speech department to initiate swallowing rehabilitation. Checking the blood circulation of the skin monitor or flap incl. Doppler control according to the scheme for 5 days. Continuation of therapy with Clexane at a dose of 0.6. Further procedure after receipt of the final histology, then presentation at the interdisciplinary tumor conference.