After induction of anesthesia and nasotracheal intubation by the anesthesiologist, a new pharyngoscopy is performed: a 4 cm large, exophytic mass is seen, which starts paramedian on the right side of the soft palate, completely affects the anterior palatal arch, extends over the retromolar region towards the cheek, is cranially approx. 5 mm from the alveolar ridge of the maxilla and infiltrates caudally via the glossotonsillar groove approx. 5 mm into the base of the tongue. Now insert the tonsil retractor and resect the mass with the electric needle. With a safety distance of approximately 1 cm. Deep dissection up to the medial pterygoid muscle and leaving a minimal layer of the posterior palatal arch. After cranial resection directly at the posterior edge of the alveolar ridge of the maxilla and also resection in the area of the cheek with a clear distance from the stenon's duct. As the mass is firmly attached to the posterior alveolar ridge of the mandible and also appears to infiltrate into the depths, it is dissected there with a safe distance to the periosteum of the mandible and from there the periosteum is pushed away from the bone with the <LOCATION> Raspa. At one point, the tumor appears to have attacked the cortical bone. The resection extends along the posterior floor of the mouth in the base of the tongue, here with an increased safety margin. The submandibular gland of the right side is exposed in depth and separated from the tumor preparation. After complete removal, the specimen is now marked with a thread (short/short = towards the uvula; short/long = towards the upper jaw; long/long = towards the base of the tongue and green thread along the lower jaw). On closer inspection, a small region between the lower jaw and the base of the tongue appears to be infiltrated right into the resection margin. Therefore, a resection is performed starting from the lower jaw along the floor of the mouth to the base of the tongue. Both preparations are sent for frozen section examination. The subsequent result shows that one site of the main preparation was indeed not healthy, but the corresponding resection no longer shows a tumor, so that a local R0 resection is present. An additional frozen section examination of the wound bed was performed, which was also tumor-free. Now insertion of a hydrogen swab and turning to neck dissection. First modified radical neck dissection type III left, level Ib to V: Curved skin incision along the anterior edge of the sternocleidomastoid. Dissection through subcutaneous tissue and platysma. Exposure and sparing of the external jugular vein. Identification of the vagus nerve, the omohyoid muscle and the posterior digaster venter muscle. An approx. 4 cm large metastasis is seen in the area of the venous angle, which makes the entire dissection difficult. Dissection of the internal jugular vein, which can be easily separated from the tumor mass. A facial vein is not found in the typical location, but much further caudally. This is now dissected from caudal to cranial, can be dissected for about 5 cm, but must then be separated due to very close contact with the tumor conglomerate. After identification of the hypoglossal nerve and skeletonization of the submandibular gland from the caudal side, the tumour conglomerate is separated from the carotid artery and sent for final histology. At the same time, the superior thyroid artery can be visualized well. Now turn to the lateral neck preparation. Expose the vagus nerve and the scalene muscles and dissect around level IIb caudally while sparing the plexus branches. Now turn to selective neck dissection of the left side, levels II to IV: Similarly curved skin incision along the sternocleidomastoid anterior edge. Dissection through the subcutaneous tissue and platysma. Long dissection and sparing of the external jugular vein and the auricular nerve. Identification of the accessorius nerve, the omohyoid muscle and the posterior digaster venter muscle. Dissection along the internal jugular vein while sparing the cervical vein. First form and remove the medial neck preparation after identifying the hypoglossal nerve and the superior thyroid artery and then form the lateral neck preparation from cranial to caudal while protecting the plexus branches. Now turn to the tracheotomy: Approx. 2 1/2 cm long, horizontal incision over the cricoid cartilage. Dissection through subcutaneous tissue, identification and spreading of the prelaryngeal musculature. Exposure of the cricoid cartilage. Directly caudal to it, the first tracheal ring on the right side appears fractured and scarred. Exposure of a very small thyroid isthmus and bipolation of the same. Now expose the anterior tracheal wall, which shows normal anatomy again caudal to the first tracheal ring. Horizontal incision into the trachea between the 2nd and 3rd tracheal ring and formation of a small Björk flap. Epithelialization of the flap using tracheostomy sutures. Re-intubation on a .................. tube. Further surgery is now dictated by <CLINICIAN_NAME>. Continuation <CLINICIAN_NAME>. Transoral resection of a right oral cavity oropharyngeal carcinoma cT2 to 3, modified radical neck dissection on both sides, tracheostoma placement, defect coverage in the oral cavity, oropharynx and tongue base area using a microvascular pedicled radial flap from the right, defect coverage on the right forearm using full-thickness skin from the left groin (<CLINICIAN_NAME>, <CLINICIAN_NAME> i. Alternation, assistance: <CLINICIAN_NAME>) Lifting of the radialis flap initially from the subfascial radial side. In doing so, protection of the nerve.......................... The radial artery is exposed and clamped. Continue the operation under pulse oximeter observation. Elevation of the radialis flap now also subfascially from the ulna, incision is continued along the forearm along the brachioradialis muscle up to the crook of the elbow in a curved shape. Inclusion of the cephalic vein in the flap as a superficial drainage system. Subcutaneous tissue is still included cranial to the skin island. Flap pedicle is exposed up to the crook of the elbow. No changes in saturation on the finger after approx. 45 min. This always remained at 100%, even after clamping the radial artery. The radial artery is therefore now disconnected and supplied caudally and cranially by means of a puncture ligature. Successive elevation of the flap along the course of the pedicle and treatment of smaller vascular branches with clips. The flap pedicle contains the superficial and deep venous system as well as the radial artery. The radial artery is dissected up to the olecranon and removed before the outlet of the interosseous artery and treated with a puncture ligature. The venous outflow is removed after the confluence of the superficial and deep venous system in the area of the cephalic vein. The vein is ligated. Flap is removed and flushed with heparin. The vascular pedicle was already freed from adventitia during dissection. Subsequent insertion of the flap into the oral cavity oropharyngeal defect: First cut through the digastric muscle from the neck side. A tunnel, 2 transverse fingers wide submandibularly, is then created as a passage for the pedicle. The flap is then inserted into the defect and the pedicle is passed through the tunnel. Successive suturing of the flap into the enoral defect using single button Vicryl 3/0 sutures. Complete defect coverage without tension. The superior thyroid artery is then exposed, dissected, freed from the adventitia, cut and ligated distally. The proximal part is prepared with the arterial anastomosis and sutured with 8/0 Ethilon single-button sutures. After opening the clamp, strong pulse and strong venous return. The access of the facial vein to the internal jugular vein is chosen for the venous anastomosis. The flap pedicle is first sutured with infrahyoid muscles to prevent kinking. The vein size is measured. A coupler size 3/0 is selected. The veins are trimmed while they are anastomized with the coupler without tension. Gelitta is inserted to prevent kinking of the vascular pedicle. The wound is then carefully rinsed again and the blood is stopped. The wound is closed in layers with the insertion of a Redon drain. A tracheal cannula with a core is inserted and fixed with sutures. The vessels of the vascular pedicle were fixed to the neck skin area using markers and checked using Doppler sonography. The procedure was completed without complications. The patient is admitted to the intensive care unit for postoperative monitoring. Please continue the antibiotic treatment started with Unacid i.v. 3 x 1.5 g. Heparin perfusor with 500 E/h for 3 days in total. Please keep patient ventilated for one night. Regular checks of the vascular pedicle by ultrasound and clinically according to the scheme. Please feed patient via inserted PEG for 10 days, then gruel and, if necessary, build up diet.