Induction of anesthesia. Intubation by anesthesia colleagues. Sterile washing and draping. Insertion of a covered retractor into the mouth and spandex. Inspection of the tongue. There is an exophytic mass in the area of the right edge of the tongue. The mass is clearly progressive. It spreads far beyond the midline to the left side. The tumor extends palpatorily to the other side, especially in the middle and posterior part of the tongue. Add <CLINICIAN_NAME> and <CLINICIAN_NAME>. The decision is made to perform the operation by means of complete tumor removal despite the significant progression of the tumor. Incision of the mucosa with the monopolar needle and successive resection of the tumor with a safety margin of at least 1 cm. The ultrasonic knife as well as conventional scissors and bipolar forceps are used for this. Only a narrow strip of mucosa remains in the area of the left base of the tongue. In this area, a complete centimeter safety margin is not possible without removing this remaining strip of mucosa. More tissue remains at the tip of the tongue. During tumor resection, the lingual artery is shown on the left side. It can be clearly seen that this artery also extends into the tumor. Consult <CLINICIAN_NAME> again. It is decided to continue the tumor resection, also removing the lingual artery on the left side. A resection must also be performed for this in order to ultimately achieve an R0 situation in this area as well. In the area of the base of the tongue, a sufficient overview cannot be guaranteed from the transoral approach. Therefore, repositioning for neck dissection. Creation of an apron flap. Neck dissection is performed on the right side, exposing the sternocleidomastoid, omohyoid and digaster muscles and the submandibular gland. Exposure of the cervical vascular sheath. Free preparation of the internal jugular vein, the facial vein and the accessorius nerve. Release of the neck preparation IIa to Va while sparing the plexus branches. Separation of the digaster venter posterior muscle. Palpation of the tumor and further tumor resection from transcervical using the pull-through technique. The tumor also involves the hyoid bone and the submandibular gland on the right side. These structures are removed en bloc with the tumor resectate. Removal of marginal samples from the specimen and sending for frozen section. Removal of two additional resected specimens, which may have been resected with a macroscopic margin. All margin samples and all resected specimens are tumor-free in the frozen section. Final R0 situation. Consultation of <CLINICIAN_NAME> and demonstration of findings. Joint planning of defect reconstruction using Remmert flap and radial artery graft. Working in a two-team procedure. <CLINICIAN_NAME> and <CLINICIAN_NAME> perform the neck dissection on the left side. Exposure of the sternocleidmastoid muscle, omohyoid muscle and digastric muscle, submandibular gland, exposure of the cervical vascular sheath. Free preparation of the internal jugular vein, the facial vein and the superior thyroid artery. Release of the neck preparation level IIa to Va while protecting the plexus branches. Lifting of the Remmert flap. Exposure of the infrahyal musculature for this purpose. Detachment of the infrahyal musculature and release of the superior thyroid artery and the facial vein. The Remmert flap remains pedicled on the superior thyroid artery and accompanying veins of the facial vein so that it can be loosely turned upwards. Parallel to the neck dissection and elevation of the Remmert flap, elevate the radial artery graft from the left. Mark the graft for this purpose. The graft is 16x9 cm in size. Skin incision and visualization of the brachioradialis muscle. Depiction of the vein star in the elbow. Depiction of a superficial vein. The cephalic vein is shown in the center. Showing the ramus superficialis nervi radialis, which is divided into several branches. Visualization of these branches. Locating and exposing the radial artery. Ligating and bypassing the radial artery. Detachment of the graft from the tendons. Dissection of the pedicle with bipolar coagulation and clipping of the branches up to the elbow. Exposure of the concomitant vein and the venous confluence between the superficial and deep system in the elbow. The concomitant veins are exposed and elevated in a confluence as well as a vein of the superficial system and the confluence marking of the radial artery. Deposition of the graft. Transition to suturing of the graft. Positioning of the flap from cervical to enoral. First fixation of the graft on the remaining tongue remnant. Transition to the neck and closure of the pharyngeal defect by placing sutures. Suturing of the graft enorally on the tongue remnant and the floor of the mouth. The flap must be rotated once to achieve three-dimensional closure of the defect. This is difficult, but is ultimately successful. Dissection at the neck of the superior thyroid artery and conditioning of this and the radial artery. Suturing the anastomosis of the two arteries. This is very problematic as the vascular situation in the neck is critical due to plaques and the blood supply to the graft is initially not fully guaranteed. An anastomosis with a long-term flowing lumen is only possible after the superior thyroid artery has been cut back several times. There is also significant reflux from the veins. Superficial and deep veins are couplerized. Perform the tracheotomy through <CLINICIAN_NAME> and <CLINICIAN_NAME> at the same time as lifting the radial artery graft. For this, insertion between the 2nd and 3rd tracheal cartilage. Creation of a Björ flap. Creation of a mucocutaneous anastomosis. At the end, creation of a mucocutaneous anastomosis in the tracheal region in the upper edge through the apron flap. Insertion of a Redon drain on the left side and a flap on the right side. After completion of the neck suture, it becomes apparent that the anastomosis on the right side is being pushed out by the skin closure. It was therefore decided to open this side again and to adapt it only slightly. Continuous perfusion of the graft is now possible. The patient goes to the IOI intubated and ventilated. Please continue antibiotics with Unacid 3 g 3 times a day and heparin 500 units/hour via a perfusor. Nutrition via the PEG tube already in place for 10 days. Then a clinical swallowing test and possibly an X-ray wide swallow. If swallowing is not possible in the long term and aspiration problems occur, a laryngectomy must be considered in the long term.