Induction of anesthesia and intubation by the anesthesia colleagues. Then insertion of a tonsillectomy tube and inspection of the tumor region. A large, exophytic tumor mass was found, starting from the tonsil on the right side, passing over to the soft palate up to the uvula and the base of the tongue. Start with transoral tumor resection in the area of the soft palate with a safety margin of more than 1 cm. Then successive tumor resection including the entire anterior palatal arch and the largest part of the posterior palatal arch and a small part of the base of the tongue on the right side. The tumor must be resected far to the side so that fatty tissue from the neck is already visible in the lateral oropharyngeal side wall. However, there is still no fistula, but the border to the soft tissue of the neck can no longer be guaranteed. Due to the large extent of the tumor resection, the lack of a soft palate and the expected fistula laterally into the soft tissues of the neck, the decision was made to cover the defect with a radialis graft. Initially, the neck dissection was performed on the left side, as it was not possible to assess whether the internal jugular vein could really remain intact on the right side. For this purpose, the sternocleidomastoid muscle, the omohyoid muscle, the digastric muscle and the submandibular gland were exposed. Then exposure of the cervical vascular sheath, dissection of the internal jugular vein, which can be completely preserved. Then expose the facial nerve and the lingual nerve of the superior thyroid artery and release the neck preparation IIa to Va while sparing the plexus branches. Neck dissection on the right side. Exposure of the sternocleidomastoid muscle, the omohyoid muscle, the digastric muscle and the internal jugular and facial veins. Exposure of the submandibular gland, removal of the submandibular gland. Dissection of the digastric muscle. Release of the neck preparation IIa to Va while sparing the plexus branches. There is also a very large lymph node conglomerate on this side, which extends from level II to level IV; this could be integrated into the neck preparation and removed without destroying the vessels and nerves. Parallel to the neck dissection on the left side, the radialis graft is lifted, here for marking the graft on the forearm, cutting around the graft and extending the skin incision into the elbow. Exposure of the venous star in the elbow, showing the superficial and deep venous system with dissection of the confluence. Exposure of the brachioradialis muscle. Exposure of the superficial ramus of the radial nerve. Exposure of the radial artery, clamping and cutting of the radial artery under pulsoxymetric control. Here 100% saturation in the left hand. Lift the graft from the veins in the usual manner, then dissect the stem up to the elbow and place the graft, taking one superficial and one deep vein with it. The transoral suturing of the transplant in the oropharynx is then very difficult, as the tongue, the uvula and the entire mucous membrane in the pharynx are already very swollen. In some cases, the graft has to be sutured into the lower area via the oropharyngotomy performed during the neck dissection. Finally, it is possible to fit the graft without tension, so that it does not tear out in the soft palate area, then repositioning to perform the anastomosis. First preparation and preparation of the superior thyroid artery. However, it turns out that there is hardly sufficient flow in the superior thyroid artery and the entire vessel is far too small to anastomose. Then turn to the lingual artery. Same problem here. Then search for the laryngeal artery, which is surprisingly relatively large and also has sufficient blood flow. Therefore, use the laryngeal artery to perform the anastomosis in the arterial area and then perform the venous anastomosis with an accompanying vein of the facial vein and the facial vein itself. The blood supply to the graft is good. Then insertion of a flap on the right side and insertion of a Redon drainage on the left side and two-layer wound closure. A tracheotomy was performed beforehand in the usual manner. This involved cutting the thyroid isthmus and performing a visor tracheotomy without a Björk flap between the 2nd and 3rd tracheal cartilage, creating a mucocutaneous anastomosis and reintubation with a tracheostomy tube. Continue antibiotics for 24 hours. The patient goes to the intensive care unit overnight and is allowed to wake up the next morning. Then nutrition via the existing PEG tube for 10 days, followed by an x-ray and food preparation.