First, another pharyngoscopy and laryngoscopy. Here again the extent of the tumor. The spread from the posterior pharyngeal wall on the right to the tonsil lobe on the left is almost circular. PEG insertion: insertion of the flexible esophagoscope. Advance into the stomach. Once the diaphanoscopy has been performed, a 15 mm stomach wall tube is inserted without any problems. This is fixed to the abdominal wall with the appropriate tension and in the typical manner. Sterile dressing. Transoral resection is now performed. The tumor is resected macroscopically on all sides with a safety margin of at least 1.5 cm in healthy tissue. The result is almost a circular defect. A mucosal bridge remains between the posterior pharyngeal wall and the left tonsillar lobe. The anterior palatal arch and posterior palatal arch are completely missing, as are parts of the posterior pharyngeal wall. However, the external carotid artery, which is not far away, is not exposed according to CT. The tumor specimen is sent for frozen section assessment together with a marginal sample taken from the transition between the tonsil lobe and the posterior pharyngeal wall on the left. Here in the frozen section, the specimen is tumor-free and the marginal sample is also tumor-free. Thus R0 situation intraoperatively. The patient is now transferred for neck dissection, right hemithyroidectomy and defect coverage. Skin disinfection and sterile draping of all relevant areas. First neck dissection and thyroidectomy on the right: skin incision curved in a typical manner. Exposure of sternocleidomastoid muscle anterior border, omohyoid muscle, digastric muscle. Exposure of the cervical vascular sheath, internal jugular artery, external/internal carotid artery, vagus nerve, hypoglossal nerve, accessorius nerve and the branches of the cervical plexus. Clearing of level II to V while protecting all structures. In any case, individual nodes in level II should be positive. Then mobilize the thyroid lobe. Difficulties with stimulation. Successive development of the right thyroid lobe with the hanging, cold nodule. Due to difficulties with stimulation, the recurrent laryngeal nerve cannot be stimulated safely and is therefore not shown, leaving a minimal amount of thyroid gland. Thyroid resection was performed by <CLINICIAN_NAME> parallel to flap elevation. Subsequent neck dissection on the left: This is performed in the same way as on the right side. Levels II to V are removed here. Suspicious nodes in level II here too. Then elevation of the radial flap from the left forearm: elevation here without tourniquet. Marking of the flap after intraoral measurement. Flap length 14.5 cm, width max. 6 cm. First cut around the flap radially. The superficial venous system is included in the flap. The radial artery is located and clamped. After clamping for at least ˝ hour, no drop in saturation. Incision is widened in the direction of the antecubital flexure. Superficial venous system is included as part of the flap pedicle. The actual flap pedicle with the radial artery and vein is exposed under the brachioradialis. The flap is then incised from the ulnar side. The flap is lifted subfascially from ulnar to radial. The radial artery is severed and supplied with puncture ligatures. The flap is lifted successively with bipolar coagulation or clipping of vascular outlets. Exposure of the connection between the superficial and deep venous system in the area of the crook of the elbow. Unfortunately, thrombosis of the cephalic vein above the connecting vein between the superficial and deep venous system occurred as a result of an indwelling venous cannula. The vein was removed here. Two larger veins can be visualized as the venous part of the pedicle, a typical confluence in the area of the radial vein and a slightly caudal branch near the connection between the superficial and deep venous system. Removal of the flap. The veins are ligated. The artery is supplied near the outlet from the brachial artery using puncture ligatures. The flap is flushed with heparin. A piece of full-thickness skin of the appropriate size is harvested from the groin area. After extensive skin mobilization, the groin is closed in several layers with the insertion of a Redon drain without major tension. Skin is successively incorporated into the defect. The wound ............ towards the crook of the elbow is closed in a typical multi-layered manner. Hydrogel is then applied to the skin graft. Application of Mepilex dressing, with a loose compress dressing on top. Wrap the hand in absorbent cotton. Fitting of a Kramer splint, which is fixed in place with an elastic bandage. Applying .............. Now cover the defect with a radial flap: First expose the vessels on the right side of the neck. Creation of a tunnel approx. 3 transverse fingers wide towards the pharyngeal space. Then successive incorporation of the flap, which extends from the left tonsil lobe over the entire palatal arch area to the right tonsil lobe and from there also covers the posterior pharyngeal wall. Incorporation of the flap using 3-0 Vicryl single button sutures successively, which proved to be difficult due to the small mouth opening. The stalk was passed through the opening into the neck area. Exposure and conditioning of the vessels. The superior thyroid artery is selected, which is anastomosed with the radial artery using 8-0 Ethilon single-button sutures. After opening the clamp, good pulse and good reflux. Subsequent anastomosis of the radial vein with a branch of the facial vein via a 2.5 mm coupler. The smaller, further branch, which shows good venous return, is anastomosed via a 2.0 coupler via the superior thyroid vein. Good venous return in each case after opening the clamp. Positive smear phenomenon. Subsequent careful hemostasis. Irrigation of the entire wound area. A tracheostomy was also created in the course of the procedure. This was performed via an extension of the skin incision on the right over the trachea. A wide pedicled Björk flap was created and initially epithelialized. After careful hemostasis, final full epithelialization of the tracheostoma and wound closure with insertion of a Redon drain on the right and left. The course of the vascular pedicle is marked with sutures. A laryngectomy tube was inserted in between. At the end, this is replaced with an 8 mm tracheostomy tube, which is fixed with sutures. Completion of the procedure without complications. Patient goes to the intensive care unit for postoperative monitoring. Nutrition via the inserted PEG tube for 10 days. Then, after swallowing gruel, diet is built up. Flap control according to scheme by means of Doppler sonography and clinical control. Antibiotics started intraoperatively with Unacid should be continued for 2 to 3 days postoperatively as perioperative antibiotics. Patient should be elevated in upper body position. Overall extensively growing oropharyngeal carcinoma cT2 to 3 cN2c. Covered by a microvascularly pedicled radial lobe. Due to the extent of the area, radiotherapy vs. radiochemotherapy should certainly be discussed according to the histological findings.