Induction of anesthesia and intubation by the anesthesia colleagues. Performance of the tracheotomy by <CLINICIAN_NAME> and <CLINICIAN_NAME>. Horizontal skin incision, approx. 5 cm in length, along an old scar following thyroid surgery. Sharp cutting of the skin, subcutaneous tissue and parts of the platysma. Dissection in depth in the direction of the infrahyoid muscles. The infrahyoid musculature is exposed and cut in the midline. Cricoid cartilage is palpated. No residual thyroid tissue is visible. Only scarring between the musculature and the trachea. The scarred tissue below the musculature is removed with pointed scissors and bipolarized. Ultimately, the trachea is well exposed. The trachea is cut open between the 3rd and 4th tracheal clasp. Creation of a Björk flap with anticipated laryngectomy and reintubation of the patient. Lifting of the apron flap by <CLINICIAN_NAME> and <CLINICIAN_NAME>. Sharp transection of the skin, subcutaneous tissue, platysma and elevation of the skin-platysma flap in a typical manner to just above the hyoid bone. The submandibular gland is exposed on both sides and the apron flap is fixed using a chain dog. Neck dissection on the left: Exposure of the anterior border of the sternocleidomastoid muscle. Exposure of the omohyoid muscle, the posterior belly of the digaster muscle, the left submandibular gland and the accessorius nerve. The cervical vascular sheath is shown. The anterior neck preparation is removed for the first time between the V. jugularis interna and V. facialis and M. omohyoideus. There are two large metastases on the internal jugular vein at level IIa. In order to gain an overview, the decision is made to remove level II b completely. This can also be done without any problems while sparing the accessorius nerve. Removal of levels III to V with protection of the plexus branches, after visualization of the vagus nerve, the internal carotid artery and the common carotid artery. Approach to level II further on the left side. Careful dissection of the two metastases from the jugular vein. Ultimately, the metastases can be removed without obstructing the jugular vein. Targeted hemostasis. This is a left neck dissection with complete evacuation of level II to V. In the case of macroscopic evidence of two metastases in level II a on the left side. Carry out the neck dissection on the right side. Exposure of the anterior border of the sternocleidomastoid muscle. Exposure of the omohyoid muscle, the posterior belly of the digaster muscle, the left submandibular gland and the accessorius nerve. The cervical vascular sheath is shown. The anterior neck preparation is removed for the first time between the internal jugular vein and facial vein and the omohyoid muscle. Level IIb is then removed above the accessorius nerve. Release of the lateral neck preparation while sparing the plexus branches and the hypoglossal nerve. The branches of the superior thyroid artery as well as the lingual and facial arteries are dissected for a possible anastomosis. Subtle hemostasis. Release of the larynx by <CLINICIAN_NAME>. Detachment of the infrahyoid muscles for this purpose. Removal of the hyoid bone. Removal of the oblique laryngeal musculature and exposure of the thyroid cartilage on the right side. Then detachment of the piriform sinus on the right side. Exposure and detachment of the thyroid gland on both sides. On the left side, the piriform sinus cannot be detached due to infiltration of the thyroid cartilage. Enter with the McIVOR oral spatula and start with tumor resection at the lower tonsil pole with the monopolar needle and at the posterior palatal arch. The soft palate is also affected and must be partially resected. Then enter the pharynx from the neck. On the right side, disluxation of the epiglottis. Incision of the mucosa along the edge of the epiglottis up to the right arytenoid cartilage. It then becomes apparent that the tumor fills the entire piriform sinus, goes down to the esophageal entrance and infiltrates the medial wall and the thyroid cartilage. The tumor is cut around with a safety margin of 1.5 cm and the larynx is placed below the cricoid cartilage and marked with a suture. Unfortunately, the vocal folds could not be preserved for the laboratory as the larynx was accidentally placed in formalin by the nursing staff. Then marginal samples were taken. All marginal samples are tumor-free in the frozen section and free of carcinoma in situ. Measurement of the defect. The defect is 15 x 10 cm in size and extends from the tonsil region across the base of the tongue via the pharynx to the entrance to the esophagus. Decision to remove a transplant. The anterolateral thigh graft is suitable for this. Lifting of the anterolateral thigh graft by <CLINICIAN_NAME>. To do this, draw a line between the lateral edge of the patella and the anterior superior iliac spine. Doppler the perforator vessels on this line. Five perforator vessels are identified and the graft is designed around the perforator vessels, 16 x 10 cm. Primary wound closure is still possible. Incision of the graft at the inferior medial edge. Expose and identify the rectus femoris muscle with its median fascia. Then identify the vastus lateralis muscle and enter the sulcus between these two muscles and identify the descending ramus of the circumflex femoral artery. The vastus lateralis is relatively thin, so that a delicate perforator graft is not lifted here and part of the vastus lateralis muscle is also lifted. Then set down. Then dissection of the pedicle and removal of the graft so that two veins remain, one large and one small. Undermining of the skin. Insertion of two Redon drains and cutting of Burow triangles and multi-layer wound closure in the usual manner. The graft is flushed with heparin and handed over to <CLINICIAN_NAME>, who then sutures the graft into the pharynx in two layers. The vascular anastomosis is performed between the facial vein and an outlet from the facial vein. The artery is connected to the common outlet of the facial and lingual arteries. There is very good graft perforation. The graft can be controlled transorally as it goes up into the tonsillar lobes. Two-layer wound closure after insertion of a flap and a Redon drainage. After the laryngectomy, a size 8 Provox-Vega prosthesis was inserted. The patient is ventilated in the intensive care unit and should be on antibiotics for at least 24 hours. Flap checks according to the usual schedule. Completion of the procedure without complications.