First of all, position the patient again and perform the pharyngoscopy and laryngoscopy: The exophytic tumor is seen, which extends from the tonsil lobe next to the uvula over the side wall into the base of the tongue or into the piriform sinus entrance. Due to the poor mouth opening and the narrow conditions, tracheostoma placement is now absolutely necessary before tumor resection for a better overview. PEG insertion: insertion of the esophagoscope. Pre-viewing into the stomach, insertion of a 15 mm abdominal wall tube in a typical manner after establishing a sufficient diaphanoscopy. This is also fixed to the stomach wall in a typical manner without any problems. Now sterile draping of all areas, injection of a total of 20 ml Ultracaine 1% with adrenaline into both sides of the neck. First tracheostoma placement by <CLINICIAN_NAME> and <CLINICIAN_NAME>. Small Kocher collar incision, dissection through the subcutaneous tissue to the infrahyoid musculature, which is split. Exposure of the thyroid isthmus, which is passed underneath, clamped, cut and supplied by means of a puncture ligature. Subsequent exposure of the trachea. Small visor flap or modified Björk flap. Epithelialization of this. Subsequent reintubation. Neck dissection on the left: Incision typically extended slightly caudally and cranially. Exposure of sternocleidomastoid muscle, exposure of digastric muscle, omohyoid muscle. Cranially there is a conglomerate of lymph nodes, which clinically corresponds to metastases. Visualization of the internal jugular vein, facial vein. Visualization of the internal carotid artery, external carotid artery, superior thyroid artery, facial artery and lingual artery. Exposure of vagus nerve, accessorius nerve, border cord and hypoglossal nerve. Clearing level II-V. Subsequent removal of the submandibular gland, including removal of some level Ib lymph nodes. Wharton's duct is ligated. The digastric muscle was also resected. Branches of the cervical plexus were exposed and preserved. Subsequent exposure of the internal and external carotid arteries and the internal jugular vein as well as the vagus nerve, hypoglossal nerve and glossopharyngeal nerve, initially up to the base of the skull. Nerves are dissected from the pharyngeal wall with vessel loops. The pharyngeal wall is lifted away from the prevertebral fascia. All soft tissues except for the hypoglossal nerve are mobilized towards the pharyngeal wall. The lateral hyoid bone and the upper parts of the superior concha are also mobilized. The lingual artery is ligated and turned laterally, as are the vein and facial artery. Then, starting transorally, the tumor is resected cranially with the entire wall. This is done caudally as far as the overview allows. Subsequently, further resection of the tumor from the transcervical side. Tumor is removed with a safety margin of at least 1.5 cm, in some cases up to 2 cm on all sides. Macroscopically clear in healthy tissue. The palatal arch falls to the left of the uvula both anteriorly and posteriorly, resection quite close to the tube. Pharyngeal wall in the area of the posterior wall up to the middle. Complete lateral wall up to the floor of the mouth in front. Resection extends into the piriform sinus, also includes parts of the vallecula up to the epiglottis and lateral parts of the base of the tongue. The specimen is marked with a suture and sent for frozen section. In the frozen section from the cranial to the alveolar ridge still severe dysplasia, also from the alveolar ridge to the base of the tongue. In situ infiltrates and partly microinvasive carcinoma caudally in the area of the entrance to the piriform sinus. Several extensive resections are therefore performed. A resection includes mucosa and some underlying tissue from the uvula to the alveolar ridge, thickness at least 1-1.5 cm. All sutures remote from the tumor. Further resection from the lateral area of the alveolar ridge to the base of the tongue via the floor of the mouth, also approx. 1 cm thick, sutures also tumor-free. A further marginal sample from the border area to the tube in the nasopharynx. Another from the caudal base of the tongue. Another caudal marginal sample is taken from the lingual epiglottis via the vallecula to the arytenoid fold and the piriform sinus, which extends medially to the resection border on the posterior pharyngeal wall. Here too, the sutures are remote from the tumor, thickness a good cm. In the frozen section, all marginal samples without dysplasia or carcinoma. Hemostasis now follows. Irrigation. Measurement of the defect size. This is 13.5 x 7.5 cm, flap is planned according to the size and required three-dimensional defect coverage. Neck dissection on the right: skin incision as on the opposite side but more limited. Exposure of the sternocleidomastoid muscle, exposure of the omohyoid muscle, exposure of the digastric muscle. Subsequent evacuation level II-IV. Exposure of internal carotid artery, external carotid artery, superior thyroid artery, facial vein, internal jugular vein. Exposure and preservation of the hypoglossal nerve, vagus nerve, accessorius nerve. Levels II-IV are evacuated, preserving branches of the cervical plexus. Subsequent careful hemostasis and layered wound closure with insertion of a Redon drainage. Then elevation of the radial flap, surgeons: <CLINICIAN_NAME>, <CLINICIAN_NAME>: Marking of the flap in the appropriate size and three-dimensional orientation. Then elevate the flap first from ulnar, subfascial, then extend the incision cranially to the olecranon. Exposure of the superficial venous system. Exposure of the connection to the deep venous system. The superficial venous system is then elevated subfascially. The flap is now elevated from the radial, subfascial side. The lateral antebrachial cutaneous nerve is exposed and preserved as far as possible. The radial artery and radial vein are exposed caudally and initially clamped. Further elevation of the flap from lateral to medial. Lift the flap off the brachioradialis muscle. Further exposure of the superficial venous system. A venencephalica can be visualized medially and laterally. The radial artery is then cut and treated using 4-0 Prolene puncture ligatures. The flap is then removed subfascially. Outgoing vessels are clipped or treated using bipolar ligatures. Lifting of the flap cranially along the pedicle. Depiction of the interosseous artery, which is severed. Exposure of the entrance of the radial artery into the brachial artery. Depiction of confluence. Subsequent removal of the flap. The veins are ligated and the artery is supplied with Vascufil 6-0 puncture ligatures. The saturation in the hand area is always within the normal range until the end of flap elevation. After removal of the flap, it is flushed with heparin. The flap is then inserted into the defect. The flap is first sutured caudally, partly with the sutures in place. Subsequently, also partly with the sutures in place on the cranial side. Sufficient, tension-free defect coverage is achieved using the flap. The pedicle is inserted caudally into the soft tissues of the neck. The facial artery is selected and conditioned for the anastomosis. After conditioning the radial artery, suture using 8-0 Ethilon single-button sutures. After opening the clamp, good arterial pulse and flow, good venous return. Then, starting from the facial nerve, one vein is conditioned for the anastomosis with the cephalic vein and a smaller one for the anastomosis with the confluence. The second cephalic vein is partly unsuitable for anastomosis due to thickened walls, probably due to scarring after infusion; it is clipped later. The smaller outlet of the facial vein is anastomosed with the confluence using a 2-0 coupler. Positive smear phenomenon after opening the clamps, good venous flow. Another outlet is clipped here. The larger outlet of the facial vein is anastomosed with the cephalic vein after conditioning using a 3-0 coupler. Here too, good venous return after opening the clamp. Positive smear phenomenon. Small outlets are also clipped here. Final inspection of the flap, which is regular. A tracheal cannula is inserted and fixed with sutures. The procedure is then completed without complications. Patient goes to the intensive care unit for postoperative monitoring. Please continue the intraoperative antibiotic treatment with Unacid 3 g for one week. Please continue heparin perfusor 500 E/h for 5 days. Control of the flap according to the scheme clinically and by means of Doppler sonography for 5 days. Site for Doppler was thread-marked. Flap control clinically well possible. Feeding via the inserted PEG tube for 10 days, followed by gruel and, if necessary, diet build-up. Overall, at least cT3 oropharyngeal carcinoma cN1-cN2b. Waiting for the final histology and presentation or discussion in the interdisciplinary tumor conference.