After induction of anesthesia and nasotracheal intubation from anesthesia, pharyngoscopy and inspection of the oral cavity are performed. Apart from the 4.5 cm exophytic tumor described above, which stops just before the midline of the tongue, there are no other abnormalities. Now flexible esophagogastroscopy and placement of the PEG tube in the typical manner using the thread pull-through method after positive diaphanoscopy. Now proceed to enoral tumor resection. The tongue is retracted and the retractor inserted. Then, using the electric needle, the tongue is cut approx. 2 cm from the tip from anterior to posterior. A safety distance of 1 cm to 1.5 cm is maintained. The muscle tissue is carefully removed from the tumor in depth. However, a cone can be seen medially, which is cut very closely. Further dissection posteriorly. Here the transition at the base of the tongue just past the midline and then resection of the glossotonsillar groove up to the lower pole of the tonsil. Laterally, the resection extends to the floor of the mouth, but does not reach the alveolar ridge. Now the entire preparation is sent for frozen section diagnostics and a small resection is also made at the lateral margin at a point that is questionable. The frozen section examination then shows that the medial situation is R1, otherwise there are no further abnormalities at the other margins. Therefore, a 5 mm thick strip is resected from the medial side with the help of scissors. This is divided into two parts, one anterior medial and one posterior medial. Both are found to be tumor-free. At the end, the defect is measured. This measures approximately 10 cm x 6 cm in size. Now proceed to neck dissection of both sides and tracheotomy. The left side is shown here first. The sternocleidomastoid muscle, digastric muscle, omohyoid muscle, internal jugular vein from caudal to cranial and also the facial vein and sparing of the latter. Also sparing of the external jugular vein. Form the lateral neck preparation from cranial to caudal, sparing the plexus branches and the accessorius nerve. Then form the medial neck preparation while protecting the hypoglossal nerve. Then resect the digastric muscle so that the perforation to the oral cavity is formed. Now proceed to the neck dissection on the right side. Identical procedure here. Identify the sternocleidomastoid muscle, digastric muscle, omohyoid muscle, free the internal jugular vein, form the lateral neck preparation while protecting the accessorius nerve and plexus branches, then also the medial neck preparation while protecting the hypoglossal nerve and submandibular gland. Now repositioning for tracheotomy. Horizontal incision here. Dissection of the subcutaneous tissue and platysma. Exposure of the pretracheal musculature and spreading of the latter. Identification of the cricoid cartilage, undermining of the thyroid gland, opening of a small window on the trachea between the 2nd and 3rd tracheal ring and reintubation on a Woodbridge tube into the trachea. Now proceed to elevate the free radialis graft on the left side: First mark the 10 cm x 6 cm graft in the caudal forearm area so that the cephalic veins are included and the flap as a whole has a radial tendency. Then draw the incision up to the elbow. Now first cut around the flap and extend the incision to the elbow. Then carefully dissect the subcutaneous area superficial to the cephalic vein using Stevens scissors. This, together with its fat pad, is now placed laterally to the brachioradialis muscle at the border of this fat pad. Now first dissect the ulnar side of the graft to secure the ulnar artery. Dissect deep down to the musculature. In particular, dissection along the tendons of the palmaris longus and flexor carpi radialis. Both are left with a minimal layer of fat on top. Now change sides and dissect the radial side again. First follow the brachioradialis muscle. In the caudal area, identify and protect the radial ramus superficialis nerve. In addition, the cephalic vein is dissected caudally and included in the graft. Now form the peripheral side of the graft. Identify the radial artery here. First clamp the last one with the bulldog for 10 minutes. A drop in saturation cannot be identified in the area of the index finger, so the radial artery is then ligated with veins. Now the deep side of the tendon of the brachioradialis muscle is removed from the graft, then dissected along the vessels of the graft (radial artery with two accompanying veins). The perforators of the vascular bundle in the direction of the deep musculature and pronator teres muscle are then successively partially bipolized and partially removed with clamps. Further cranially, the radial artery is now followed very carefully. The confluence of both accompanying veins in the deep venous system is identified and the anostomosis of the deep venous system to the cephalic vein is dissected and protected. The antebrachial cephalic vein is seen to branch into a very beautiful cephalic vein in the upper arm region and a basilic vein. Both are further dissected to a length of approx. 3 cm and then separated. At the same time, the radial artery is followed up to the bifurcation with the ulnar artery. The ulnar artery is then digitally pressed, causing the pulse on the pulse oximeter to disappear. This provides a second confirmation of the ulnar vein. The radial artery is now also removed 1 cm before this outlet. Now flush the radial artery with heparin until it comes out of the veins. Then place the radial artery graft in warm water. A large graft of split skin is then removed from the right thigh. The thigh is then covered with Opsite sheets. The split-thickness skin graft is then used to cover the defect on the left forearm. A VAC dressing is not used, but a forearm splint is sutured again with Mepilex under considerable pressure. The radialis graft is now sutured very carefully to the edge of the tongue, from anterior to posterior. Suturing the base of the tongue is quite difficult here. The vessels are then freed of fibrin again on the left neck and the superior thyroid artery is further dissected to a length of approx. 5 cm and then removed. The latter shows a lumen that is smaller than the radial artery, which is why it is incised obliquely and then sutured microscopically using 8-0 ethilon sutures. After opening the micro-staples, the suture is found to be insufficient. This is then repaired with additional sutures. It is now apparent that sufficient blood is coming out of the venous end of the radialis graft. For this reason, the cephalic vein is then anastomosed with the facial vein using the coupler system. At the end of the operation, placement of a flap on the left side and a Redon drainage on the right side and transfer of the patient tracheotomized and ventilated to the intensive care unit. The patient should continue to receive antibiotics for at least 3 days and should only be fed via the PEG. The flap should be checked every two hours and the first cannula change should take place on day 5. The patient has a heparin perfusor running at 500 units per hour after the anastomosis; this should be continued for 3 days.