After induction of anesthesia and intubation by the anesthesiology colleagues and anesthesiological preparation, the primary tumor area was inspected again. This revealed an extensive mass in the area of the soft palate with a completely tumor-infiltrated uvula, extensive infiltration of the soft palate with significant submucosal infiltration. The tumor reaches the upper tonsillar lobe on the right side, also just on the left side. Overall transverse diameter of the tumor over 4 cm, therefore T3 extension. No tumor growth beyond the tonsillar lobe to the caudal side. PEG tube inserted first. Here, insertion with the gastroscope, under laryngoscopic control, easy advancement into the stomach. If diaphanoscopy is good, the stomach is punctured without any problems and the PEG tube is inserted using the usual suture pull-through method. Subsequent repositioning of the patient with preparation for microvascular defect reconstruction. First turn to tumor resection. For this purpose, the tumor is resected with a safety margin of a good 1 cm with consecutive subtotal soft palate resection. Tonsillectomy is performed if the tumor has spread to the upper pole of the tonsil on both sides. For a better overview, the anterior palatal arch is removed on both sides. The tonsil capsules on both sides are regular, on the left side circumscribed transition to the posterior palatal arch. Generous resection here too. The back of the soft palate can now be explored. Tumor growth towards the submucosa, but no mucosal infiltration. Successive development of the tumor and resection of the tumor macroscopically in toto. Removal of the soft palate and both tonsil lobes. In the submucosal preparation, a slightly narrower approach to the tumor capsule is seen in the area of the soft palate on the right side, which is why a complete definitive resection is performed here. All margins are then covered with margin samples, all of which are assessed as tumor-free. An R0 resection can therefore be assumed here. The tumor and the resected margin are sent for definitive histology. The graft required to cover both tonsil boxes and to restore the soft palate is now measured. The graft measures a total of 13 x 6.5 cm. The neck dissection and radialis graft removal are now performed in parallel to the neck dissection. Start with the right side. Make a curved skin incision on the anterior edge of the sternocleidomastoid muscle, cut through the skin and subcutaneous tissue. Expose and cut through the platysma. Exposure of the sternocleidomastoid muscle, omohyoid muscle, exposure of the submandibular gland, exposure of the digastric muscle. Removal of the neck preparation with careful protection of the facial vein, the superior thyroid artery and the hypoglossal nerve. Free preparation of the internal jugular vein. Overall, due to the patient's anatomy and the somewhat varied course of the vessels, the preparation conditions were considerably more difficult. Exposure of the accessorius nerve, dissection of the accessorius triangle with careful protection of the nerve and dissection of level V with careful protection of the cervical plexus branches. Level Ib is then evacuated with extirpation of the submandibular gland. This is followed by resection of the digastric muscle and a pharyngotomy measuring approx. 2 ˝ QF to position the pedicle. Overall, several nodules in the neck area, conspicuous in size and number, without infiltration of neighboring structures. In principle, the same procedure was used on the left side. Cut through skin and subcutaneous tissue. Exposure and transection of the platysma. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Exposure of the submandibular gland and the digastric muscle. Ligation of very strong superficial veins with drainage into the anterior jugular vein and external jugular vein. Clearing of the anterior neck preparation with preservation of a deep facial vein branch, a superficial facial branch is removed. Exposure and preservation of the superior thyroid artery and hypoglossal nerve. Dissection of the internal jugular vein. Numerous lymph nodes can be seen in the area of the very deep vein angle. Macroscopically highly visible nodus measuring approx. 3.5 cm. Careful dissection of the accessorius nerve, but this can be preserved. Clearing of the accessorius triangle with careful preservation of the nerve and clearing of level V with careful preservation of the cervical plexus branches. Subsequently skeletonize the submandibular gland and evacuate level Ib while carefully protecting the oral branch. Careful wound inspection and palpation, followed by wound irrigation with H202 and Ringer's solution. Insertion of a 10-gauge Redon drain and careful two-layer wound closure. At the same time, the radialis graft was harvested from the left forearm. After marking the graft, the tourniquet was applied. Cutting around the graft. Radial exploration of the cephalic vein. Perform the Haydn maneuver to identify the superficial ramus, radial nerve. Locate the distal vascular pedicle. Dissection after ligation. Ulnar dissection with exposure and visualization of the flexo carpi ulnaris. Complete detachment of the graft by strict subfascial dissection, proximal dissection of the pedicle including the drainage area of the cephalic vein. Careful clipping of outgoing veins in the antecubital fossa. Exposure of the extremely strong bridge of the radial veins into the cubital veins, including the cephalic vein. Positioning of the venous system to the side and exposure of the radial artery with securing of the outlet of the ulnar artery, reopening of the tourniquet. Careful, meticulous hemostasis with a regular graft. After removal of the graft, the wound is carefully closed in two layers in the forearm area and the full-thickness skin graft harvested from the groin is inserted. The vacuum sealing pump is then applied and the Cramer splint is placed in the functional position. For full-thickness skin harvesting from the right groin, incision of a full-thickness skin graft measuring approx. 14 x 6 cm, strictly cutaneous elevation. Subcutaneous mobilization, insertion of a 10-gauge Redon drain after careful wound inspection and hemostasis. Subsequent strong two-layer wound closure. The radialis graft is now inserted. Successive insertion with significantly more difficult insertion conditions due to the swelling that has now occurred and the rather strong radialis graft, successive insertion. Finally, good reconstruction of the soft palate with the graft still in place. Careful cervical stem displacement. Cervical preparation of the right side of the facial vein and the superior thyroid artery. The facial artery is also prepared. This is followed by anastomosis with the superior thyroid artery due to a jump in the caliber of the suture. After initially regular flow, there is now a lack of venous flow. Cessation of pedicle pulsation, therefore reopening of the artery in case of occlusion. Due to the rather unfavorable caliber conditions, preparation of the facial artery and renewed arterial anastomosis with 8.0 Ethilon. This now works well. Immediate regular venous return and excellent graft perfusion so that venous anastomosis with the coupler system is performed after preparation of the flap vein and the facial vein. After measuring a size 3.5 coupler, anastomosis is performed without any problems. Subsequent regular graft perfusion. Careful cervical wound inspection, wound irrigation and subsequent insertion of a guided 10 Redon drainage and careful two-layer wound closure. Due to the significant swelling that has now set in, a plastic tracheostomy is then performed. A horizontal incision is made at the level of the cricoid cartilage. Cut through the skin and subcutaneous tissue. Ligation of superficially pronounced veins. Dissection of the infrahyoid muscles. Exposure of the cricoid cartilage. Exposure of the very deep trachea. Exposure and transection of the thyroid isthmus. Exposure of the anterior surface of the trachea. This shows a clear ........ or ossification of the trachea. Entry between the 2nd and 3rd tracheal ring. Somewhat laborious creation of a broad-based Björk flap with clear ossifications in the area of the tracheal clasps. Subsequent insertion of the tracheostoma with generally difficult insertion conditions due to the cartilage conditions. Subsequently, problem-free reintubation to a size 9 low cuff cannula and, after final enoral inspection with a vital graft, termination of the procedure at this point. Conclusion: Intraoperative R0 resected cT3 cN2c soft palate carcinoma. Reconstruction using a radialis graft. Due to the initial graft swelling and the more difficult adaptation conditions, the patient should not be given food until the 10th postoperative day. With proper graft healing and swallowing function, timely closure of the tracheostoma should be possible.