Induction of anesthesia by the anesthesia colleagues, transoral intubation and then sterile washing and draping of the neck area and creation of a tracheotomy by <CLINICIAN_NAME> and <CLINICIAN_NAME>. Injection of 5 ml Ultracaine with added Suprarenin along the skin incision. Sterile abjoration. Marking of the skin incision. It runs in a line 5 cm long between the cricoid and a point 2 transverse fingers above the jugulum along the median line on the neck. Now sharply cut through the skin, subcutaneous tissue and platysma with the 15 mm scalpel. The anterior jugular vein is exposed and is ligated and cut. Further dissection in depth. The linea alba and the infrahyoid musculature are found. Here dissection after bipolar coagulation. The thyroid gland is now revealed. With the Overholt clamp, the thyroid isthmus is undercut and bipolarly coagulated. A visor tracheotomy is performed between the 3rd and 4th tracheal ring and mucocutaneous anastomosis with Ethibond sutures in the typical manner. Then insertion with the flexible gastroesophagoscope and placement of the PEG through <CLINICIAN_NAME> and <CLINICIAN_NAME>. Entry with the gastroesophagoscope and air insufflation into the stomach. Once in the stomach, endoscopy of the cardia after inversion of the endoscope. A spontaneous diaphanoscopy can now be seen. A PEG is now placed in loco typico on the anterior wall of the stomach using the suture pull-through method. This was performed without any problems. The patient received Unacid 3 g i.v. perioperatively. Then sterile washing and draping and positioning of the patient and start of inspection of the tumor region by <CLINICIAN_NAME>. The tumor extends from the right tonsil to the right palatal arch, passes to the uvula and also extends to the left palatal arch, covering the anterior and posterior palatal arch and the entire soft palate. On the right side, the entire tonsil is tumorously altered and also the pharyngeal side wall up to the vallecula. The base of the tongue is only marginally affected. Now start with transoral tumor resection in the area of the soft palate, the uvula and the soft palate. Then further dissection along the pharyngeal side wall and in the area of the medial parts of the pharynx. Then perform the neck dissection on the right side. To do this, expose the sternocleidomastoid muscle, the submandibular gland, the omohyoid and digastric muscles, the accessorius and hypoglossal nerves and the cervical vascular sheath. Then removal of the metastases and the neck preparation from level II a to V a. Unfortunately, parts of the cervical plexus and the hypoglossal nerve must also be resected here. Then continue the tumor resection from transcervical. To do this, the submandibular gland must be removed and the digastric muscle severed. Then disluxate the tumor and remove the remaining tumor tissue. In the area of the medial pharyngeal border, the tumor resection appears relatively close. A generous resection and a marginal specimen are performed here. Ultimately, all margin samples in the frozen section are R0. Parallel to the tumor resection, the radialis graft is lifted. Due to the resection, the radialis graft is relatively narrow in the caudal section. The pharynx must be gathered here. Carry out the neck dissection on the left side through <CLINICIAN_NAME> and <CLINICIAN_NAME>.Enter with the 15 mm scalpel and make a skin incision along the anterior border of the sternocleidomastoid muscle from the mastoid to the caudal, in a curved line along the anterior border of the sternocleidomastoid muscle. Sharp transection of the skin, subcutaneous tissue and platysma. The external jugular vein is exposed, ligated and cut. The platysma flap is now dissected using a scalpel. Dissection along the anterior edge of the sternocleidomastoid muscle in depth. The accessorius nerve is now exposed and protected. The accessory nerve is followed in a cranial direction and the posterior belly of the digastric muscle can now be seen. Further medially, the submandibular gland can be seen, which is also easily visualized. The omohyoid muscle is visible caudally. The cervical vascular sheath is visible in the depth below several neck metastases. The internal jugular vein is exposed from caudal to cranial. There is no injury to the structures here. The superior thyroid vein and facial vein are dissected and spared. Medial to the jugular vein, the common carotid artery and the external carotid artery are exposed as well as the vagus nerve and the cervical artery. The neck preparation is now detached in level II b, followed by level II a while sparing the accessorius nerve, and levels III/IV and V are also detached without difficulty. The plexus branches are visualized and specifically spared. No chyle fistula occurs caudally when the neck preparation is removed. The anterior neck preparation is now also exposed and dissected along the facial vein and the superior thyroid vein. Clinically clear evidence of multiple cervical lymph node metastases on the left side. Thus cN2c neck status. The hypoglossal nerve is shown cranially; the nerve is also clearly spared on this side. Elevation of the radial forearm flap on the left by <CLINICIAN_NAME>: Palpatory identification of the distal radial artery. Marking of the flap borders (13 x 7 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 M. pronator quadratus and M. flexor pollicis longus with ligation of the outgoing perforators using a vessel 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. Defect coverage 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. The graft is sutured in place by <CLINICIAN_NAME>, who also performs the anastomosis in the area of the neck vessels. After removal of the radial artery flap, it is flushed with heparin solution. Insertion of the flap into the defect. It becomes apparent that the defect size slightly exceeds the flap size due to the post-resection. However, the flap can be sutured successively into the defect without tension, sometimes with the sutures in place. Sutures with single button sutures 3-0 Vicryl. The entire defect is successfully covered, except for a small portion in the area of the posterior pharyngeal wall. Here the flap is sutured to the prevertebral fascia. Otherwise, the base of the tongue, pharyngeal side wall and palatal arch area are covered. A gastric tube is inserted to ensure the nasopharyngeal passage. The stalk passed through the right side of the neck is then anastomosed. The superior thyroid artery is selected for the anastomosis. After conditioning, this is sutured to the radial artery or anastomosed with 8-0 Ethilon single-button sutures. After opening the clamps, good arterial flow, good venous return. Subsequent conditioning of the cephalic vein. This is relatively poorly patency distally, but after cutting it back there is good venous return further proximally. The accompanying vein of the radial artery is selected as the 2nd connecting vein, which is, however, very thin. After conditioning the vessels with a 2.5 mm coupler, the cephalic vein is anastomosed with a venous outlet from the middle thyroid vein. Good venous flow after opening the clamps, positive smear phenomenon. The remaining part of the cephalic vein is clipped. The small accompanying vein of the radial vein is anastomosed with another outlet from the thyroid vein using a 1.5 mm coupler after conditioning the vessel ends. Here too, after opening the clamps, good flow, good venous return and positive smear phenomenon. Enoral flap control shows good aspect. Subsequent irrigation of the right side of the neck, hemostasis, layered wound closure and insertion of a total of 2 flaps. Epithelialization of the tracheostoma. This is fixed with stitches. Completion of the procedure without complications. The patient is admitted to the intensive care unit for postoperative monitoring. Flap monitoring for 5 days according to the scheme clinically and via the marked area of the vascular pedicle using vascular Doppler. Continue antibiotics started intraoperatively for a total of 1 week. Feeding via the PEG tube. After approx. 10 days, gruel swallowing and, if necessary, diet build-up. After receiving the final histology, presentation at the interdisciplinary tumor conference.