After induction of anesthesia with intubation and preparation of the patient by the anesthesia colleagues, the patient is first positioned. A pharyngoscopy is performed to determine the current extent of the tumor. An exulcerated tumor with infiltration of the lateral and posterior floor of the mouth with transition via the posterior floor of the mouth to the anterior palatal arch and circumscribed to the tonsillar lobe is found on the right edge of the tongue. The tumor grows submucosally from anterior to posterior in the area of the tongue margin, increasingly infiltrating and reaching approx. 1/3 of the extent in the area of the tongue base, in the area of the tongue base completely submucosal tumor growth. The vallecula, epiglottis and pharyngeal side walls are tumor-free. Therefore, first turn to transoral tumor resection. The tumor is cut around with the monopolar and later with the dissection technique, maintaining a safety margin of just under 1 cm in the mucosal area and 1.5 cm in the tongue area. In the area of the tongue muscles, widening of the safety margin. Resection of the soft palate section with removal of the tonsil lobe in the sense of a radical tonsillectomy. Retention of the posterior palatal arch and the uvula. Resection of the entire posterior floor of the mouth. The alveolar ridge is reached here, but no infiltration, therefore incision of the mucosa and detachment with the freer. After mobilization in the tongue area and removal at the mucosal level, it is now apparent that the tumour is clearly growing submandibularly and towards the base of the tongue. No complete transoral control here. Therefore, after complete release in the mucosal area except for the base of the tongue, turn to the transcervical approach to complete the tumor resection. Now reposition the patient. Skin incision on the anterior border of the sternocleidomastoid muscle on the right. Cut through skin and subcutaneous tissue. Exposure and dissection of the platysma. Dissection of the platysma. Exposure and preservation of the external jugular vein. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Exposure of the submandibular gland and the digastric muscle. Level II shows a coarse, extensive and infiltrative growing metastasis, which was seen with clear infiltration of the muscle when the sternocleidomastoid muscle was dissected. The sternocleidomastoid muscle was therefore removed caudally at the level of the omohyoid muscle. Exposure and free dissection of the internal jugular vein, after cranial dissection removal of level V with careful protection of the cervical plexus branches. Free dissection of the internal jugular vein up to above the exit of the superior thyroid vein. This shows clear infiltration by the metastasis. There is also infiltration of the accessorius nerve. Deposition of the internal jugular vein above the aforementioned thyroid vein. Separation of the accessorius nerve and removal of the accessorius triangle. Exposure and dissection of the common carotid artery with bulb. Here the metastasis pulls hard on it, infiltrates the hypoglossal nerve, which must be removed, as well as direct contact with the ascending pharyngeal artery and occipital artery, both of which are also removed after ligation; later the lingual artery and facial artery are also ligated and removed. Resection of the metastasis as well as in toto, after removal in the case of circumscribed infiltration, of the digastric muscle. Free dissection of the carotid branches. The anterior neck preparation was removed while preserving the superior thyroid artery. Extirpation of the submandibular gland and thus also basal removal of the floor of the mouth. Evacuation of level I b with careful preservation and exposure of the ramus marginalis mandibulae. Several nodules here. Extension of the pharyngotomy dorsally. Completion and visualization of the resection area via both access routes. Checking the entrance in the area of the pharyngotomy. This is at a clear safety distance from the tumor. Good overview now. Resection and removal on the side wall of the pharynx and resection of the tumor with removal of a good 1/3 of the base of the tongue with macroscopic resection as far as in sano. Previously, completely covering marginal samples were taken in the area of the enoral margins. Completion of the transcervical margin samples in the area of the base of the tongue and the pharyngeal side wall. These are completely assessed as tumor- and dysplasia-free in frozen section diagnostics. Therefore, an R0 resection can now be assumed for completely imaged margin samples. This results in a wide pharyngeal defect. Measurement of the pharyngeal defect and design of the flap format. Based on the tongue resection, the decision is now made to remove a transfemoral graft. At the same time, the neck is dissected on the left side. Neck dissection. Skin incision on the front edge of the sternocleidomastoid muscle. Separation of skin and subcutaneous tissue. Exposure and dissection of the platysma. Exposure of the sternocleidomastoid muscle, omohyoid muscle, exposure of the submandibular gland and the digastric muscle. Release of the anterior neck preparation with careful protection of the cervical artery, the superior thyroid artery, the facial vein and the hypoglossal nerve. Free preparation of the internal jugular vein. Clearing of level V with careful protection of the cervical plexus branches and the cervical artery. Subsequent evacuation of the accessorius triangle with careful protection and exposure of the nerve. Followed by careful wound inspection and, if the wound is dry, wound irrigation. Insertion of a 10 Redon drain and careful, two-layer wound closure. Elevation of the transfemoral graft. After marking the orientation marks and identifying the intermuscular septum, the skin perforators are now identified using Doppler sonography. This is extremely laborious. It is only possible to identify a small perforator in the mid-thigh area using Doppler sonography. Decision for exploration. Marking of the graft. This is specially configured for the base of the tongue and soft palate, with a total length of 15 cm and a width of up to 6 cm. Medial incision. Cutting through skin and subcutaneous tissue. Dissection of the thigh fascia. Expose and secure the rectus femoris muscle. Now inspect the intermuscular septum. It can be seen that there is no perforator in the intermuscular septum between the vastus lateralis and the rectus femoris. However, from the septum, between the intermedius and the lateral vastus, a perforator can be seen entering the graft at an identified point; with very strong vessels of the lateral femoral artery medially, the decision is now made to explore the perforator with the possibility of a perforator flap if necessary. Tracing of the slender perforator after tracing under the intermedius muscle. Rapid increase in perforator thickness with opening into the extremely strong vascular pedicle. Therefore complete dissolution of the intermedius muscle. Identification and dissection of a further, even smaller perforator. Complete release from the muscle and thus preparation of a perforator flap. Isolation of the graft on the vascular pedicle and placement of the vital graft, also isolation on a strong artery and vein. Careful wound inspection and irrigation. Then insertion of a 10 Redon drain and careful, multi-layer wound closure with resection of excess skin. The graft is then inserted. This is done transorally and transcervically. Overall good fit with complete coverage of the defect. Upon insertion, the left canine tooth is loose, with an overall marod tooth status. This was extirpated. However, further inspection reveals a tooth status with several loose teeth that is in great need of restoration. Insertion of the graft. Dense conditions on all sides. Therefore, conditioning of the neck vessels on the right for anastomosis. Conditioning of the superior thyroid artery and the superior thyroid vein, which has excellent flow through the caudally preserved internal jugular vein. Conditioning of the flap vessels. Perform the arterial anastomosis with 8-0 Ethilon. This is successful and immediately sufficient. Tight conditions in the area of the anastomosis and immediate regular venous return. Therefore conditioning of the superior thyroid vein. Measurement of a size 4-0 coupler and easy passage of the venous anastomosis with the coupler system. Subsequently, regular circulation and pulsation with excellent graft perfusion. Therefore, after final wound inspection, insertion of a guided 10 Redon drain and subsequent careful, two-layer wound closure. The tracheotomy was performed at the same time. For this, a skin incision was made approx. 1 cm below the cricoid cartilage. Cut through the skin and subcutaneous tissue. Exposure and splitting of the infrahyoid musculature. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. Insertion between the 2nd and 3rd tracheal ring. Creation of a broad-based pedicled Björk flap and incision of the tracheostoma with mucocutaneous anastomosis. Subsequent problem-free intubation onto a size 8 low-cuff cannula, which is suture-fixed. Final inspection. Vital graft. Repositioning of the patient and completion of the procedure without any indication of complications. Conclusion: Intraoperative R0 resected cT3 cN2c oral cavity/oropharyngeal carcinoma. Complex reconstruction due to the anatomical conditions, flap size and defect location. Extended radical neck dissection and tumor resection on the right with additional resection of the hypoglossal nerve and the lingual nerve.