First reclination of the head, opening of the mouth with a mouth retractor, tongue lashing. Remove the carcinoma with a safety margin of at least 1.5 cm to 2 cm on all sides. For this purpose, resection of the left side of the tongue except for a small remnant at the tip of the tongue up to the midline, dorsally, caudally up to and including parts of the base of the tongue. To the side, resection of parts of the floor of the mouth. Partial resection of the lingual nerve and the sublingual gland as well as the wharton duct. Resection extends dorsally to the tonsil region. Preparation goes to the frozen section. Here, all margins are in the healthy area, thus R0 resection. Rearrangement for neck dissection on the left: First disinfect the skin. Injection of a total of 10 ml Ultracaine 1% with adrenaline into both sides of the neck. Start with the left side. Curved skin incision. Exposure of sternocleidomastoid muscle anterior margin. Dissection of fat lymph node package from the muscle. Exposure of the omohyoid muscle, digastric muscle. Exposure of the internal jugular vein, internal/external carotid artery. Visualization of vagus nerve, accessorius nerve and hypoglossal nerve. Then develop the dorsal neck preparation while preserving the branches of the cervical plexus. Then develop the anterior neck preparation while exposing and preserving the superior thyroid artery and the lingual artery. Due to the resection of the wharton's duct, the submandibular gland with attached level b lymph nodes is also removed. In this case, the branch of the mouth is exposed in a short section. Finally, careful hemostasis. Irrigation of the wound area. This results in a neck dissection II-IV. Neck dissection on the right: Here the operation is performed as on the opposite side, but only level II and III evacuation with preservation of all structures as on the opposite side. Enlarged lymph nodes on both sides can be removed. Supraomohyoid neck dissection on the right due to cN0 status on ultrasound. Then measurement of the defect in the area of the tongue and floor of the mouth. Flap size resulted in 10 x 5.5 cm. The radial flap is then removed: mark the flap in the appropriate size. Apply the tourniquet after unwrapping the arm. Then cut around the flap subfascially from the ulnar side, later from the radial side. Incision curved towards the crook of the elbow. Exposure of the superficial venous system. This consists of several veins which open into the cephalic vein. This shows 2 ends. The brachioradialis muscle is then shown, with the pedicle below. Distal exposure of the radial artery. This is severed and supplied with prolene using 4-0 stitches. Distal also anti-shear suture on the flap. Successive lifting of the flap under its vascular pedicle. Outgoing vessels are clipped or bipolar coagulated. Dissection successively in the direction of the olecranon. The connection between the surface and deep venous system can be visualized and preserved. The radial artery is very thin-lumened overall, the connection to the brachial artery is very far cranial. Beforehand, the interosseous artery is severed and ligated. Very very thin radial vein, which is not suitable as an anastomosis. Very thick brachial and ulnar arteries. Finally releasing tourniquet. There is a good hyperperfusion phenomenon of the flap. However, blood flow starts with some delay, so the flap is initially left in situ to prevent reperfusion ischemia. In the meantime, the neck was dissected on the right side. The flap is now removed and the veins and artery ligated using a puncture ligature and clip. Two large connecting veins and the very small radial vein can be removed, as well as a relatively small radial artery. Now suture the flap into the defect: To do this, create a 2-3 QF wide tunnel from the oral cavity to the left cervical. To do this, cut the digastric muscle which is coagulated in a bipolar fashion. Then pull the pedicle through into the neck. Care is taken to ensure that it does not ..................................... The flap is successively worked into the defect without tension using 3-0 Vicryl single button sutures. The vessels are then conditioned. The superior thyroid artery, which has a similarly thick lumen as the radial artery, is treated first. The lingual artery is also dissected. First anastomosis of the radial artery with the superior thyroid artery after conditioning of the vessels. Suture with Ethilon 9-0 sutures. After opening the clamps, initially good perfusion with good venous return. In the course, however, insufficient perfusion and undescribed venous return. The anastomosis was therefore opened and checked. No thrombosis. Repeated suturing with Ethilon 9-0 sutures. Then open the clamp again. Here too, completely insufficient arterial flow and venous return. Doppler signals equally unconvincing. Clamping of the superior thyroid artery again and opening of the suture. No thrombosis recognizable here either. The decision was made to use the prepared lingual artery, which had to be severed anyway, as a bleeding prophylaxis for the anastomosis. The lingual artery is placed in a high position here and ligated cranially. The lingual artery is now conditioned and sutured to the newly conditioned radial artery, whereby the radial artery must be cut open narrowly due to the differences in lumen. Suture with 9-0 Ethilon single-button sutures. After opening the clamp, strong arterial flow and good venous return are restored. The facial vein and the larger part of the cephalic vein are now conditioned. After conditioning and measuring the vessels, a size 3 coupler is selected. This is used in the typical manner. The vessels are stretched over the silicone pins. After the coupler is closed, however, the pin gets between the silicone rings and the metal pin is pressed into the vessel. The vessels are conditioned again and the coupler is reinserted in the same way as size 3. The coupler is finally successfully placed by applying pressure from the outside to the .......................... After opening the clamps, good venous flow, positive smear phenomenon. Another coupler anastomosis is performed with a larger vein, which is also in contact with the internal jugular vein. Coupler size also 3.0. Here too, pressure must be applied to the coupler externally to prevent the bolt from drifting through the silicone rings. Good venous return here too, positive smear phenomenon. Subsequent careful irrigation and hemostasis. Final view shows good arterial perfusion and venous return, flap vital and well perfused. Wound closure in layers on both sides of the neck and insertion of a Redon drain in each case. Anastomosis region marked externally using suture. The forearm is closed using skin removed from the right side of the groin: First mark the 10 x 6 cm groin skin. Remove the skin as a full-thickness skin graft. After mobilization of the skin edges and careful hemostasis, layered wound closure of the fatty skin and also the groin skin using 3-0 Vicryl, 2-0 Vicryl and 4-0 Ethilon back-stitch sutures with insertion of a Redon drainage. Finally, sterile dressing. Then incorporation of the full-thickness skin into the defect. The wound is closed cranially in a typical layered manner. Then apply a hydrogel Mepilex dressing. Compresses are loosely applied over this. The hand is then fixed to a Cramer splint using an elastic bandage. Finally, tracheotomy: small Kocher collar incision due to the severe swelling with the tongue protruding from the mouth area. Exposure of the infrahyoid musculature. After spreading these, the thyroid isthmus is exposed. This is passed underneath, severed after clamping and treated with puncture ligatures. The trachea is then exposed. A free-stemmed Björk flap is created in the 2nd/3rd intercartilaginous space. Epithelialization of this. Subsequent insertion of an 8 mm tracheal cannula. Re-intubation. Tracheal cannula is fixed with sutures. ......................plast dressing on puncture sites. Redon, otherwise no dressing and no cannula tape. Check the flap again enorally, it is vital. Completion of the procedure without complications. Patient goes to the intensive care unit for postoperative monitoring. Please continue the antibiotic treatment started intraoperatively for 2-3 days. Also continue the heparin perfusor therapy started intraoperatively with 500 E/h for a total of 5 days. Regular checks of the flap or Doppler sono checks according to the schedule. PEG placement was attempted intraoperatively, but this measure was not possible in the absence of diaphanoscopy. A gastric tube was therefore inserted intraoperatively. The patient was to be fed via this gastric tube for 7-10 days. In the event of swallowing problems, a PEG tube must be inserted secondarily by colleagues in internal medicine or surgery. Total cT2 tongue margin carcinoma on the left, which was resected in sano and the defect was covered with a radial flap. Intraoperatively enlarged but not highly suspicious cervical lymph nodes on both sides. Postoperative presentation at the interdisciplinary tumor conference.