First pharyngoscopy to confirm extension: The exophytic tumor is seen, which extends from one tonsil lobe on the left to the other and also grows posteriorly towards the nasopharynx. Now transoral resection: The tumor is removed macroscopically on all sides with a safety margin of approx. 1.5 cm in healthy tissue. The entire tonsil lobe on the left, the entire palatal arch up to the hard palate or the beginning of the vomer and the entire tonsil lobe on the right as well as on the left side up to the base of the tongue are removed. The tumor is resected macroscopically on all sides in healthy tissue. Suture marking. This is followed in the middle of the palatal arch in the direction of the vomer by a marginal sample with mucosa and soft tissue. This is also thread-marked for frozen section diagnostics. The tumor on the left caudal side, below the tonsil pole in the direction of the base of the tongue is not yet healthy, otherwise healthy on all sides, and the marginal sample is also healthy. Therefore, another extensive resection is performed in the area of the posterior palatal arch in the caudal region, the anterior palatal arch and parts of the base of the tongue. Subsequently, a marginal sample is taken from the area mentioned, which is thread-marked and sent for frozen section. No more tumor infiltrates here. Thus overall R0 status. This is followed by repositioning for neck dissection and defect coverage using a radial flap. Sterile covering of all areas. Start with neck dissection on both sides (<CLINICIAN_NAME>): Start with neck dissection on the right side: mark a curved skin incision along the sternocleidomastoid muscle on the right side, then dissect through the subcutaneous tissue, initially sparing the external jugular vein, exposing the anterior border of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Exposure of the submandibular gland. Finding the digastric muscle and following it to the mastoid. Visualization of the hypoglossal nerve. Then locate the accessorius nerve, which is spared. Finally, the internal jugular vein and the facial vein are dissected in their course. Now develop the lateral neck preparation from level IIb to IV while sparing the cervical plexus and exposing the carotid artery and vagus nerve. All structures can be spared. Now follow the cervical artery and develop the anterior neck preparation while sparing all vascular structures. Finally, careful hemostasis and wound irrigation and then proceed to the creation of a plastic tracheostomy. Marking of a skin incision below the cricoid cartilage. Dissection through the subcutaneous tissue, ligation of two larger veins matching the anterior jugular vein, then separation of the infrahyoid musculature. Exposure of the cricoid cartilage and undermining of the thyroid isthmus which is ligated on both sides. Now expose the anterior tracheal wall and incision in the 3rd cartilage interspace while sparing the cuff. Finally, creation of a classic Bjlörk flap and epithelialization of the tracheostoma with single-button sutures, which is completely tension-free. Now reintubation. Then proceed to neck dissection on the left side. In principle the same procedure as on the right side, exposing the anterior border of the sternocleidomastoid muscle. Trace the omohyoid muscle. Expose the glanular submandibular muscle which is retracted. Now expose the hypoglossal nerve and follow the digastric muscle. Dissection of the internal jugular vein and exposure of the accessory nerve, which is spared. Now also develop the lateral neck preparation from level IIb to IV. Then follow the cervical artery and develop the anterior neck preparation while sparing all neurovascular structures. Here too, hemostasis using bipolar coagulation and wound irrigation. We now move on to the microvascular anatomy on the right side of the neck. Elevation of the radialis flap from the left forearm: After measuring the defect enorally, the flap is 13 cm long and a maximum width of 6 cm. The flap is first incised from the ulnar side. A curved incision is then made in the crook of the elbow. Exposure of the superficial venous system. Subfascial elevation of the flap from the ulnar side. Exposure of the vascular pedicle. Exposure distal to the radial artery. This is clamped. Lift the flap subfascially from the radial side. The flap remains at 100% for 10-15 minutes after the radial artery has been clamped. The radial artery is then removed. Treatment with puncture ligatures 4.0 Prolene. Then lift the flap along the pedicle. Outgoing smaller vessels are coagulated bipolar or treated with clips. Lift the flap with the vascular pedicle and superficial venous system into the crook of the elbow. A double outlet of the cephalic vein, a connection to the deep venous system, can be visualized here. After clamping, the interosseous artery can also be removed. Flap perfusion is always 100%. No suitable confluence can be visualized in the area of the radial vein, several smaller vessels, some of which are less than 1 mm. The flap is then removed, the artery is clamped and sutured with 6.0 Vascufil above and below the inner surface. The veins are ligated. The flap is flushed with heparin. Then lift a piece of full-thickness skin of the appropriate size for the defect from the groin area on the right. After mobilizing the skin, the groin is closed in layers with the insertion of a Redon drain. The skin is successively worked into the defect. Cranial primary wound closure without tension. Dressing with hydrogel/Mepilex. Over this, cloud dressing and wrapping in absorbent cotton. A Cramer splint and loose wrapping in an elastic bandage is applied on top. Hand always well supplied with blood. Saturation at 100%. Good capillary pulse. Application to the hand. Now creation of a two transverse finger wide tunnel from the pharynx on the right into the soft tissues of the neck. Insertion of the flap into the defect. Insertion of the pedicle into the right side of the neck. Successive incorporation of the flap with 3.0 Vicryl single button sutures with low tension. The entire palatal arch area can be covered. In the area of the tonsillar lobe on the left, a portion of the defect in the caudal area of the pharyngeal wall remains uncovered by the flap while the pharyngeal wall is still very well preserved. Tension-free situs. Subsequent vascular anastomosis. Conditioning of the radial artery and the superior thyroid artery. Suture with 8.0 Ethilon single-button sutures. After opening the clamp, good arterial flow, good venous return. Conditioning of two venous outlets from the facial artery. These are each anastomized with 2.5 mm couplers after vessel conditioning. After opening the clamp, good venous return in each case. Smear phenomenon positive in each case. Extensive hemostasis again in both sides of the neck. Wound closure in layers with insertion of a Redon drain on the left and a guided Redon drain on the right. Finally, insertion of a 9 mm tracheostomy tube, which is fixed with sutures. Completion of the procedure without complications. The patient is admitted to the intensive care unit for postoperative monitoring. Please continue intraoperative antibiotics for 2-3 days with Unacid. Heparin perfusor, which was started intraoperatively at 500 I.U./hour, should be continued postoperatively for 5 days. Monitor the flap according to the scheme using clinical checks and Doppler checks. For this purpose, mark the suture on the right side of the neck in the area of the stalk. Feeding via inserted PEG tube. After approx. 10 days, gruel swallowing and, if necessary, food build-up. Overall cT2-3 palatal arch/oropharyngeal carcinoma on both sides. Defect covered by radial flap. Clinically no clear indication of lymph node metastases, but metastases on both sides possible with enlarged lymph nodes. After receiving the histology, please discuss in the interdisciplinary tumor conference.