After preparation and intubation by the anesthesia colleagues, a pharyngoscopy was performed and the extent of the tumor was checked again. An exophytic tumor was found in the area of the uvula with markedly uneven mucosal extensions towards the soft palate and the tonsillar lobes on both sides. Overall, however, the tumor is somewhat left-sided. The tonsils themselves are inconspicuous and free, no significant deep growth. Submucosal growth was ruled out, so that the tumor was initially resected en bloc with a safety margin of a good 1.5 cm. After safe complete resection, the tumor is resected with tonsillectomy on both sides. Left Performing a tumor tonsillectomy with removal of the anterior palatal arch on the right side. Classic tonsillectomy using the dissection technique, providing a good overview of the posterior palatal arch and the posterior surface of the soft palate. Resection macroscopically far in sano with subtotal removal of the soft palate, the tumor is also completely resected in sano on the specimen. Now removal of completely covering margin samples. The invasive carcinoma is resected in sano, but in the area of the posterior surface of the soft palate, with a macroscopic safety margin of approx. 2 cm, there is discontinuous Cis at the edge of the deposit, so a complete resection is performed here as well as the removal of an additional covering margin sample, which shows no higher-grade dysplasia or Cis, so that the final situation is R0. After measuring the defect, the patient is turned to PEG placement. The gastroscope is inserted under laryngoscopic control into the stomach without any problems, here with excellent diaphanoscopy, the stomach is punctured without any problems and the PEG tube is inserted using the usual thread pull-through method. The patient is then repositioned. Injection of xylocaine with adrenaline in the neck area. Initially, due to the extensive soft tissue infiltration and infiltration of the internal jugular vein on the left, turn to neck dissection on the right to secure the vascular status. Curved skin incision on the anterior edge of the sternocleidomastoid muscle. Separation of skin and subcutaneous tissue. Exposure and transection of the platysma. Exposure of the sternocleidomastoid muscle, omohyoid muscle, submandibular gland and digastric muscle. Removal of the anterior neck preparation with careful protection and preservation of the strong facial vein, the extremely slender superior thyroid artery and the hypoglossal nerve with cervical anus. Free preparation of the internal jugular vein. Exposure of the accessorius nerve, clearing of the accessorius triangle with careful protection of the nerve. Subsequent evacuation of level Va with careful protection of the cervical plexus branches, here macroscopically no suspicious nodules overall so that after wound irrigation the procedure is moved to the opposite side. Here, with infiltration of the directly subcutaneously located metastasis of the caudal parotid gland, the incision is curved around the lobule in the direction of the mastoid and then diverted cervically. Cut through the skin and subcutaneous tissue, preserving the platysma caudally. Exposure of the sternocleidomastoid muscle and the omohyoid muscle. Anterior exposure of the submandibular gland and the digastric muscle, which is clearly infiltrated in the area of the posterior venter. Release of the lobule, dissection down to the mastoid, the mass infiltrates the sternocleidomastoid muscle over a wide area directly into the subcutaneous level, here infraauricularly thin conditions, so that cloudy secretion is discharged at points when attempting to dissect the skin, therefore leaving the entire skin area, here above the metastasis en bloc resection, here of a spindle of 2 x 2.5 cm and thus complete coverage, otherwise no skin infiltration. Dissection of the soft tissue mantle. After visualization of the cervical vascular sheath caudally and safe infiltration of the sternocleidomastoid muscle and the internal jugular vein, the muscle and vein were removed. Careful protection of the common carotid artery and the vagus nerve. Cranial dissection first of level V. Numerous nodules here, additionally here also circumscribed black pigmented changes, corresponding to the aspect of melanin changes, complete removal. Caudal preservation of the cervical plexus. Complete cranial resection. Here, the mass is broadly overlying and infiltrating the paravertebral musculature. Extremely aggressive perinodal growth. Complete resection of the paravertebral musculature. Exposure of the carotid bulb and the hypoglossal nerve, which can be preserved. Clearly no infiltration. Infiltration of the branches of the external carotid artery, here the occipital artery, the facial artery. Separation of the vessels, otherwise no carotid infiltration. Cranial complete rupture of the jugular-facial angle, the vein can only be deposited in a healthy state just below the base of the skull, here treatment with ligature and puncture. Infiltration of the sternocleidomastoid muscle as far as the mastoid, therefore the periosteum is completely taken away. Bone infiltration. Infiltration of the caudal parotid gland, here showing the marginal mandibular nerve, which can just be detached from the mass without infiltration drawings. Otherwise no growth towards the facial nerve trunk. Mobilization of the non-infiltrated submandibular gland and complete evacuation of level Ib while leaving the gland intact and removal of the metastasis en bloc in toto with macroscopic in sano resection. Subsequently, careful treatment of the detached vessels, wound irrigation with H202 and Ringer's solution and insertion of two 10-gauge Redon drains as well as careful two-layer wound closure and circumscribed execution of relief incisions to close the current defect. The radialis graft is then removed from the left forearm. Marking of the graft, measuring a total of 11.5 x 5.5 cm with a special configuration for the soft palate and tonsil lobe. Creation of the tourniquet. Cutting around the graft. Widening of the skin incision towards the crook of the elbow. Initial radial dissection. Exposure of the cephalic vein, which is taken along the lateral edge of the graft. Identification and careful protection of the radial superfacial nerve ramus. Exposure of the distal vascular pedicle, ligation of the distal vascular pedicle. Free preparation of the brachioradialis muscle, followed by ulnar preparation. Exposure of the flexor carpi ulnaris muscle. Strictly subfacial release of the graft, proximal pedicle preparation including the cephalic vein. Exposure of a strong venous vascular bridge between the deep venous system and the strong cephalic vein. Exposure of the radial artery after securing the outlet of the ulnar artery. Subsequent reopening of the blood vessel with vital margins and vital graft. Careful hemostasis and removal of the graft. After careful hemostasis, the wound is closed in two layers and the full-thickness skin graft harvested from the right groin is implanted. The vacuum pump is then applied and the Cramer splint is placed in the functional site. Full-thickness skin harvesting from the right groin: For this purpose, incision of an area measuring approx. 12 x 5 cm, strictly cutaneous elevation. Subcutaneous mobilization, careful hemostasis and, after insertion of a 10 mm Redon drainage, careful multi-layer wound closure under moderate tension. The graft is then implanted after the right-sided pharyngotomy has been performed. This involved resection of the posterior digastric muscle. The pharyngotomy is performed transorally and transcervically. Widening of the pharyngotomy with as little muscle resection as possible. Creation of a 2.15 finger-wide tunnel. Insertion of the graft, successive suturing. This succeeds well and adequately with a good fit and complete coverage of the pharyngotomy. The graft vessels are then conditioned. The arterial vessels are then explored. Here, the arterial vessels on the right side are extremely narrow and calibrated. Proximal preparation of the facial artery, here somewhat stronger conditions. Due to the position, the arterial anastomosis is now performed with 8.0 Ethilon under significantly more difficult suturing conditions. Overall laborious adaptation, but finally sufficient anastomosis with immediate venous return. Conditioning of the facial vein and implementation of the venous anastomosis using the coupler system with a coupler size 4.0. Subsequent regular pedicle pulsation. Positive spreading phenomenon and vital graft enorally, so that after final wound inspection on the right cervical side, a 10-gauge Redon drain was inserted, followed by careful two-layer wound closure and completion of the procedure with a vital graft without any indication of complications. Note: The patient received intraoperative intravenous antibiotics with Unacid 3 g, which should be continued for 24 hours postoperatively. Conclusion: Intraoperative R0 resected cT2 cN3 left-sided uvular carcinoma, extended radical neck dissection with subtotal removal of the cervical plexus and paravertebral musculature. Postoperative careful flap monitoring with vital conditions and regular enoral healing, gradual food intake can be started from the 7th postoperative day. A tracheotomy was deliberately avoided in the case of completely thin enoral conditions and no exposed wound surface. If the wound heals properly, prompt presentation for planning the absolutely necessary adjuvant therapy in the case of extremely aggressive and rapidly progressive cervical metastasis.