Induction of anesthesia and intubation by the anesthesia colleagues transnasally. Then start of the tumor resection from the transoral side. Insertion of a tonsil plug and inspection of the oropharynx and oral cavity. A relatively fresh lesion with irregular mucosal changes is found in the area of the uvula. As it cannot be guaranteed whether this lesion existed previously or was caused by the intubation, a biopsy is taken and sent for a frozen section. No evidence of dysplasia or invasive carcinoma in the frozen section. Therefore, start with tumor resection. The tumor extends onto the soft palate and moves along the alveolar ridge of the mandible into the tonsil region, infiltrates and completely consumes the tonsil, continues down the lateral wall of the oropharynx on the left and spreads to the base of the tongue here, infiltrates the base of the tongue on the right side, merges into the vallecula. The epiglottis is free. Now start with the tumor resection in the area of the soft palate, here macroscopic safety distance approx. 1 cm. The tumor is cut around with the monopolar needle. The tumor resection is now extended to the alveolar ridge. The tumor also infiltrates the posterior palatal arch. This is removed as well as part of the pharynx. The area of the cervical fat is reached relatively quickly and since the overview in the caudal area is no longer given, the tumor is now washed and covered sterilely in order to continue the tumor resection later from the transcervical area. Now make a skin incision at the anterior margin of the sternocleidomastoid muscle. Exposure of the anterior margin of the sternocleidomastoid muscle. Here you can already see large metastases in level II. Visualization of the omohyoid muscle, visualization of the cervical vascular sheath. It is clear that the internal jugular vein is infiltrated by a large metastasis at level III, so the internal jugular vein is removed below this metastasis. The neck levels IIa to Va are then cleared out, sparing the plexus branches. The neck levels are sent separately for histology as part of the lymph node study. Level Ia and b are then evacuated with removal of the submandibular gland and transection of the digastric and stylohyoid muscles. Level I also contains conspicuous nodes, which are all removed. A breakthrough is now created enorally and the tumor is removed via this breakthrough using the pull-through technique. Marginal samples are taken from the tumor specimen itself and sent for frozen section; all marginal samples are tumor-free. This means that the tumor itself is removed from the R0 specimen. Now measure the defect and move on to the radialis graft. Start by elevating the radialis graft with <CLINICIAN_NAME>, then continue with <CLINICIAN_NAME>, at the same time carry out the neck dissection on the right side with <CLINICIAN_NAME>, here also making a skin incision on the anterior edge of the sternocleidomastoid muscle. Exposure of the platysma, exposure of the omohyoid and the sternocleidomastoid muscle. Exposure of the cervical vascular sheath and clearing of the neck levels IIa to Va while sparing the plexus branches. Here too, the neck levels are sent in individually as part of the lymph node study. The vascular situation here is also relatively poor. There is only a tiny superior thyroid artery, which is not suitable for subsequent connection to the radial artery. The lingual artery cannot be removed as it had to be resected on the left side as part of the tumor resection. The ascending pharyngeal artery is so small that it is also not available as a flap vessel. Only a very small facial artery would be possible. There is also only one vein available as a venous connecting vessel, namely the facial vein, which is also very thin. Dictation of the radial artery flap. Marking of the graft 14 x 6 x 6 cm is configured so that both the pharyngeal and soft palate defect can be covered, as well as the tongue base defect. Incision of the graft. Incision in the proximal area of the forearm. Then exposure of the brachioradialis muscle. Exposure of the superficial fascia of the radial nerve, which can be completely spared with its branches. Exposure of the radial artery. Clamping, ligation and ligation of the radial artery, then lifting of the radialis graft from the tendon bed. The ulnar artery is palpable in depth. Pulse oximetry on the index finger shows a continuous good blood supply to the hand, even after the radial artery has been removed. Then dissection of the pedicle up to the elbow. This shows an anatomical variation, so that the radial artery is dissected further up into the upper arm area and can only be removed at its high exit. Two venous vessels are also elevated, both of which belong to the superficial system, but a very good confluence between the superficial and deep venous system can also be elevated. The radialis graft is then removed. It can now be seen that one superficial vein has no venous return flow and the second vein only has a weak return flow. Overall, it can be seen that the entire radial artery is also in a very poor condition in terms of the endothelium. Nevertheless, there is no further possibility of lifting another graft. This graft must be used. This is also due to the fact that the left side is not available as a graft in the absence of sufficient perfusion in the radial artery area and the AED is also not suitable for use in the case of severe obesity. Suturing the graft first from the transoral side and then later from the transoral side is again difficult due to swelling. Sutures must therefore be placed in the caudal area and the graft retracted. Now create an opening from the cervical left to the cervical right. The stalk is then transferred to the right side. Dissect the facial artery as the connecting vessel and the facial vein. Then first suture the arterial anastomosis. Good flap perfusion at the beginning. However, the venous return flow is then interrupted so that the entire arterial anastomosis has to be sutured again. This condition then occurs again, so that up to a third anastomosis must be made in the arterial limb. For this, large sections of the radial artery have to be cut back and also the facial artery due to the very poor vascular condition in the vessel itself, there are endothelial-like deposits both in the neck and in the radial artery, some of which are calcareous, which makes suturing the anastomosis considerably more difficult. Ultimately, good flap perfusion can be maintained over a longer period of time with an albeit limited, moderate venous return flow. The facial vein is now connected to the one remaining flap vein using a coupler. Due to an unfavorable flap situation, this has to be repeated so that ultimately extremely difficult conditions exist in the anastomosis area, but a stable anastomosis could be created at the end of the operation. Due to the special situation, the patient was given 500 E/h heparin intraoperatively, which was to continue for 5 days. At the end, a flap was inserted on the right side and a Redon drainage on the left side. Prior to this, a tracheotomy was performed in the usual manner and the neck was closed in two layers. The patient was admitted to the intensive care unit on mechanical ventilation. Continue antibiotics for at least 24 hours, preferably for 3 days. Then 5 days heparin 500 E/h, for 2 days please 2-hourly flap controls, then continue according to the usual scheme and present the patient to the tumor conference after receiving the histology.