Tracheotomy: After demonstration of the findings on <CLINICIAN_NAME>, a tracheotomy is performed with a longitudinal incision to avoid an apron flap if bilateral neck dissection is necessary. Injection of 5 ml Ultracaine with Suprarenin added. Cauterization and sterile draping. Incision between the cricoid cartilage and a point three transverse fingers above the jugulum measuring approx. 5 cm. Now cut through the skin, subcutaneous tissue and platysma with a 15 mm scalpel. Enter with the pointed scissors and expose the infrahyoid musculature, linea alba and finally the thyroid gland. Incision with the Overholt clamp below the isthmus, the thyroid gland, between the thyroid gland and the trachea. Bipolar coagulation of the isthmus and transection of the isthmus. No injury to the surrounding structures. Truncus is checked or palpated and not injured. Now insertion between the second and retrotracheal ring and creation of a visor tracheotomy in the typical manner. The mucocutaneous anastomosis is performed without difficulty using Ethibond sutures. PEG insertion: Insertion with the flexible gastroesophagoscope and, under air insufflation, pre-scanning into the stomach. Gastric mucosa unremarkable, without irritation. Inversion shows no tumor in the cardia. A spontaneous diaphanoscopy is performed in loco typico, paramedian left, three transverse fingers below the ribs. A PEG is then inserted at this site using the thread pull-through method without any problems. Traction loosening should take place in 24 hours. The patient received Unacid 3 g i.v. perioperatively. Tumor resection and neck dissection on the left. After positioning and sterile washing and draping of the patient, insertion of the McIvor mouth blocker and inspection of the tumor region. The tumor extends from the left tonsil onto the anterior palatal arch up to the uvula and caudally to the glossotonsillar groove and the base of the tongue. The resection is first started with the monopolar needle in the area of the soft palate. Safety distance 1 to 1.5 cm. The entire anterior palatal arch must be removed. Then move on to the tonsil region. Further dissection with scissors and bipolar forceps so that the tonsil is removed together with the tumor tissue. The musculature must also be removed in depth and the soft tissues of the neck are accessed. The neck fat becomes visible. Then further dissection in the area of the glossotonsillar groove and the base of the tongue, part of the base of the tongue is also removed. Medially, the largest parts of the posterior palatal arch are also removed due to tumor infiltration. The specimen is placed on cork for frozen section. The frozen section still shows moderate dysplasia in the area of the soft palate. A superficial resection is performed and a marginal sample is sent to the frozen section. This is then tumor-free. Then transition to neck dissection on the left side. Skin incision in a transverse skin fold. Exposure of the sternocleidomastoid muscle. Exposure of the submandibular gland. Exposure of the omohyoid muscle and exposure of the cervical vascular sheath. Removal of the neck preparation II a to V a, sparing the plexus branches. The accessorius nerve and hypoglossal nerve are exposed and spared. Now widen the opening enorally so that 3 transverse fingers can be comfortably inserted into the mouth area. The flap pedicle is to be pulled through here later. Now dissect the connecting vessels. Dissection of the superior thyroid and facial vein as well as the external jugular vein. The patient has a good vascular situation and several options for connection. Radialis flap: Palpatory identification of the distal radial artery. Marking of the flap boundaries (size) 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. Neck dissection on the right: injection of 10 ml Suprarenin along the skin incision on the front edge of the right sternocleidomastoid muscle. Use the 15 mm scalpel to sharply cut through the skin, subcutaneous tissue and platysma. The external jugular vein is now ligated. The ramus auricularis magnus is severed. Dissection of the platysma flap and dissection along the anterior edge of the sternocleidomastoid muscle. Exposure of the cervical vascular sheath. The accessorius nerve is explored cranially. The nerve can be visualized without difficulty. The nerve is traced cranially to the posterior belly of the digastric muscle. The posterior belly of the GSM is also visualized. The omohyoid muscle is dissected and traced cranially. The jugular vein is now dissected from caudal to cranial. Level II b is detached, followed by II a, III, IV and V in depth. The ACC and the vagus nerve are exposed and spared. The anterior neck preparation is detached from the internal jugular vein and facial vein without any problems. The hypoglossal nerve is exposed and spared. Hemostasis using bipolar forceps. At the end of the procedure, there is no bleeding. Placement of a 10 Redon drain. Platysma suture using 4.0 Vicryl and skin suture using 4.0 Ethilon. The nervus accessorius showed an anatomical variant and ran above the jugular vein. The nerve was also spared. After removal of the graft, it is rinsed with heparin, then the flap is sutured into the defect: first sutures are placed, the graft is inserted and the pedicle is passed through the large tunnel. The flap is successively sutured into the defect with 3-0 Vicryl single-button sutures, folded in the palatal arch area. This results in tension-free, complete defect coverage. The superior thyroid artery and radial artery are then conditioned for vascular anastomosis. This is performed with 8-0 Ethilon single-button sutures. After opening the clamps, good arterial flow, good venous return. Subsequent conditioning of the veins, here conditioning of the two outflows from the superficial venous system. The deep venous system is clipped in the course of the operation. Two outlets of the facial vein are selected, the larger outlet is anastomosed with the larger outlet of the cephalic vein after conditioning the veins using a 3-0 vascular coupler. Here, after opening the clamp, good venous return, positive smear phenomenon. The smaller vein with a smaller outlet from the facial vein is then anastomosed using a 2-0 coupler. Here too, after opening the clamp, good venous return, positive smear phenomenon. Subsequent irrigation of the wound area. Wound closure in layers with insertion of a Redon drain on the right and 2 flaps on the left. Subsequently, after epithelialization of the tracheostoma, fixation of the cannula using sutures. Close inspection of the flap. This is vital. The procedure is then completed without complications. The patient is ventilated postoperatively for monitoring in the intensive care unit. Please continue antibiotics, which were started intraoperatively with Unacid, for 1 week. Continue heparin perfusor 500 units per hour for a total of 5 days. Flap control according to the scheme for 5 days, both clinically and by Doppler sonography. A suture marker was placed on the left side of the neck for this purpose. Feeding via the PEG tube for approx. 10 days, then gruel swallowing and, if necessary, diet build-up. After receiving the final histology, presentation at the interdisciplinary tumor conference to plan further treatment.