Induction of anesthesia and transoral intubation by the anesthesia colleagues. First laryngoscopy and pharyngoscopy: The exophytic tumor can be seen growing into the wall in the area of the pharyngoepiglottic plica transition or starting just below the lower tonsil pole and lying in the area of the lateral piriform sinus on the left. Free arytenoid fold. Transition medially to just on the posterior hypopharyngeal wall. Overall indication for flap coverage probably with preservation of the larynx. Now inject a total of 10 ml Ultracaine 1% with adrenaline into the sides of the neck. Subsequent sterile draping of all areas including radial flap and thigh flap. Start with tracheostoma creation: Kocher's collar incision, slightly widened, which can later be widened into an apron flap. Subsequent dissection through subcutaneous tissue up to the anterior jugular vein, which is cut and ligated on both sides. The infrahyoid muscles are then pushed apart. Exposure of the thyroid isthmus. This is passed underneath, clamped, severed and then ligated using puncture ligatures. Then exposure of the trachea. Enter the 2nd/3rd intercartilaginous space. Incision into the trachea in the sense of a visor tracheotomy. Subsequent epithelialization in the caudal area. Re-intubation and insertion of a laryngectomy tube. Repositioning and sterile washing and draping. Creation of an apron flap in the usual manner. Carry out the neck dissection on the right side. To do this, expose the sternocleidomastoid muscle, the omohyoid muscle, the submandibular gland and the digastric muscle. Then expose the cervical vascular sheath. It is clear that the jugular vein is infiltrated by a long metastasis. This is deposited in the area of level IV and also deposited at the top. Then the sternocleidomastoid muscle is deposited, which is also infiltrated in the midfield. The accessorius nerve and the cervical plexus must also be removed, so that ultimately only the hypoglossal nerve and the common carotid artery as well as the division of the internal and external arteries remain. The metastasis extends far dorsally into level V b and is completely removed with the neck block. Transition to the other side. The sternocleidomastoid muscle, submandibular gland, omohyoid muscle and digastric muscle are also shown here. Exposure of the cervical vascular sheath and removal of the neck block II to V, sparing the plexus branches, sparing the accessorius nerve and the hypoglossal nerve. Now enter again with the Kleinsasser tube and inspect the tumor. An ulcer-like tumor can be seen, which begins below the tonsil lobe. Determine the entry limit into the pharynx. Then enter the pharynx from the left. Cut around the tumor with a safety margin of 1.5 cm. The specimen is placed on cork for frozen section. In the frozen section, all edges of the specimen are tumor-free and free of carcinoma in situ. Now measure the defect, 12 x 8 cm, and transition to the forearm. Draw a graft of the appropriate size and then palpate the radial artery and ulnar artery. Application of a 300 mmHg tourniquet and cutting of the graft and extension of the incision into the crook of the elbow. Exposure of the venous star in the crook of the elbow. Exposure of the cephalic vein, the basilic vein and the venous confluence. Dissection of the brachioradialis muscle. Dissection of the superficial ramus of the radial nerve. Exposure of the radial artery. Lifting of the graft from the tendon bed, protecting the ulnar artery and the tendons. Dissection of the pedicle up to the crook of the elbow. Then the stem is removed by <CLINICIAN_NAME> so that superficial and deep veins remain intact for connection. At the end, close the wound on the arm in the usual way. The tendon of the palmaris longus muscle must be removed in the distal area, as it stretches very far upwards and would probably pass through the split skin. Finally, a dorsal forearm splint was placed. In the meantime, <CLINICIAN_NAME> lifted the split skin from the right thigh in the usual way and then transplanted it to the left forearm. Subsequent suturing of the flap into the defect: The flap is sutured successively into the defect with 3-0 single Vicryl button sutures so that a tension-free closure is achieved and the pedicle can be passed to the opposite side for the vascular connections. Dissection of the facial vein and another small outlet directly between the facial and internal jugular veins. For the venous connections and dissection of the facial artery for the arterial anastomosis. Also removal of the submandibular gland for this purpose and for a better overview. Ductus wharton is ligated twice. Subsequent conditioning of the flap vessels and repeated heparin irrigation. The facial artery is sutured to the radial artery using 8-0 Ethilon single-button sutures. Opening of the clamp, good arterial flow, good venous return. The confluent vein is anastomosed to the small outlet between the internal jugular vein and facial vein using a 2-0 coupler. After opening the clamp, good venous return, positive smear phenomenon. The larger of the cephalic branches is then anastomosed to the facial vein using a 3-0 coupler. After opening the clamp, good venous return, positive smear phenomenon. The other outlet had already been clipped when the flap was removed. Subsequent careful hemostasis, irrigation. Closure of the wound with epithelialization of the tracheostoma in layers in a typical manner with insertion of a Redon drain on the left and insertion of 2 flaps on the right. Re-intubation. Insertion of a tracheal tube, which is fixed with sutures. The procedure is then completed without complications. Patient transferred to intensive care unit for monitoring. Please continue antibiotics administered intraoperatively for one week. Upper body elevation. Control of the flap clinically or by Doppler at the marked or suture-fixed site anteriorly on the neck for 5 days according to the control scheme. Feeding via the previously inserted PEG tube for at least 10-12 days, then gruel swallow and, if necessary, diet build-up. Overall cT2-3 hypoharyngeal carcinoma with cN2c status. Postoperative presentation at the interdisciplinary tumor conference.