Introductory consultation with the anesthesiologist. After appropriate preparation, oropharyngoscopy is performed once again: the ulcerated tumor can be seen here, which appears to be limited to the tonsil but extends laterally on palpation. Insertion of the PEG tube After entering the stomach and postoperative diaphanoscopy, the tube is inserted under visualization. This is done without any problems. Application of a wound dressing. Infiltration with local anesthetic in the neck area. Performing the tracheostomy: To do this, sharply cut through the skin and subcutaneous fatty tissue. Push apart the prelaryngeal muscles, undermine the isthmus of the thyroid gland and expose the pretracheal lamina. Then opening of the trachea between the 2nd and 3rd tracheal clasp and easy reintubation of the patient. Placement of the lower stoma sutures for mucocutaneous anastomosis. Then sterile washing and draping of the neck, arm and right thigh. Start with the neck dissection on the right side. Here, while protecting all non-lymphatic structures, regions I to V are evacuated after exposure and skeletonization of the sternocleidomastoid muscle. Neurolysis of the accessorius and hypoglossal nerves and re-embedding of the nerves. The superior thyroid, lingual and facial arteries are then exposed at their exit from the external carotid artery, thus shifting the external carotid artery laterally until the tumor can be safely bypassed. The lingual artery on the right side cannot be preserved as it runs through the middle of the tumor, so it is removed. The hypoglossal nerve is completely skeletonized and can be preserved until the end. On palpation, the tumor extends to just above the hyoid bone. The pharynx is then opened caudal to the tumor and cranial to the hyoid bone in the area of the lateral hypopharyngeal wall. The tumor is then successively developed completely from the transcervical side under visual control and resected with an appropriate safety margin. Histology is then taken from the mucosal margins. These are all found to be tumor-free on frozen section histology. Subsequent measurement of the defect with a 7 x 5.5 cm defect. Transition to neck dissection of the left side. This is performed in the same way as on the right side after visualization and skeletonization of the sternocleidomastoid muscle, including displacement, neurolysis and re-embedding of the accessory nerve and hypoglossus. Here too, all non-lymphatic structures are spared and regions II to V are removed. Closure of the left side of the neck using multi-layered sutures after insertion of a Redon suction drain. Application of a pressure dressing. Elevation of the radial forearm flap on the left Palpatory identification of the distal radial artery. Marking of the flap boundaries (7 x 5.5 cm) on the distal forearm, proximal to the flexor retinaculum, with an S-shaped incision running proximally into the cubital fossa. Incision of cutaneous and subcutaneous tissue starting proximally. Identification and visualization of the venous confluence in the cubital fossa. Identification of the cephalic vein and dissection of the vein distally with integration into the radial graft margin. Identification of the ramus externus of the radial nerve and elevation of the radial portion, leaving the peritendineum of the tendons of the brachioradialis muscle intact. Subsequent ulnar incision down to the forearm fascia. Incision of the fascia and subsequent subfascial elevation of the ulnar edge of the graft up to the tendon of the flexor carpi radialis muscle. Care is taken to leave the peritendineum on the flexor tendons and to spare the ulnar artery. Identification of the distal radial artery and trial clamping with a vascular clamp. After 5 minutes with good oxygen saturation measured by pulse oximetry (measured on the index finger), the vessels are removed with subsequent ligation (Prolene 6.0). Successive detachment of the flap pedicle from the pronator quadratus and flexor pollicis longus muscles with ligation of the outgoing perforators using a vascular clip into the cubital fossa. Exposure and protection of the radial nerve on the medial side of the brachioradialis muscle. Exposure of the brachial artery, V. mediana cubiti, A. ulnaris. First removal of the radial artery, then of two veins of the superficial venous system. Vascular ligation by means of a bypass ligature (artery) and vascular clip (veins). Subtle hemostasis in the area of the wound bed using bipolar coagulation forceps. Two-layer wound closure in the area of the proximal forearm. Covering of the graft bed with split skin from the right thigh in the usual manner. Suturing of preparation swabs. Application of a wound dressing and a forearm splint. Completion of the graft lift without complications. After appropriate development of the radial lobe graft, it is inserted transcervically into the defect. The radialis flap is then sutured transorally into the right oropharynx. The last caudal sutures in the area of the base of the tongue and the lateral hypopharyngeal wall are performed transcervically, resulting in complete tension-free closure of the defect. Check again transorally. The two anastomoses are then performed. First, the arterial anastomosis is performed after appropriate preliminary preparation of the superior thyroid artery. The large caliber vein, which accommodates the superficial as well as the deep drainage area of the flap, is attached to the internal jugular vein in an end-to-side anastomosis. No bleeding visible on final check with vital graft. Insertion of a Redon suction drain as well as an Easy-Flow drain. Multi-layer wound closure on the right cervical side. Application of a pressure dressing. Control of the flap transorally, whereby the graft is absolutely vital. Re-intubation of the patient onto an 8-gauge Rügheimer cannula, which is fixed to the skin. Application of a neck bandage. Final consultation with the anesthetist. Conclusion: Transcervical resection of a tonsillar carcinoma on the right side with selective neck dissection on both sides. Defect coverage via a microvascularly anastomosed radial artery flap graft from the left forearm. The arterial anastomosis is made via the superior thyroid artery. The venous anastomosis forms an end-to-side anastomosis to the internal jugular vein. Defect coverage on the left forearm via a split-thickness skin graft from the right thigh. Additional tracheotomy and PEG placement.  