First, after induction of anesthesia, renewed panendoscopy: The tonsillar carcinoma on the right, as described above, was found to be over 4 cm in size, extending to the hard palate and the mandible. Decision to perform transoral tumor resection. Recheck of the vocal fold findings: Here the findings are rather inconspicuous. Based on the histology, decision to perform laser resection. Initial PEG placement 9 Charričre: insertion of the flexible esophagogastroscope. Inspection of the gastric mucosa and oesophagus and then placement of the gastric tube under strict diaphanoscopic control. Fixation of the holding plates and repositioning for laser resection: Here, the tumor is excised relatively superficially from dorsal to anterior after power with 5 watts and continuous mode of <CLINICIAN_NAME>. 2 anterior and dorsal margin samples are sent for frozen section histology. Here, dysplasia is still found in the dorsal part, and a new microlaryngoscopic ablation is performed in the dorsal part, well within the normal healthy area, for final histological assessment. Hemostasis with a supratip. If the wound is inconspicuous, repositioning for modified radical neck dissection on the right side: curved skin incision. Exposure of the anterior edge of the sternocleidomastoid after cutting through the platysma. No ligation of the external jugular vein, but lateral displacement to reduce lymphoedema. Exposure of the internal jugular vein. Now from caudal to cranial mobilization of the sternocleidomastoid. Locate the accessor nerve, which is found, dissected further cranially and spared in the further course of the operation. Establish the upper resection margin at the belly of the digaster muscle, which is followed ventrally. Now lateral to the internal jugular vein, place the caudal neck preparation in the area of region IV. No conspicuous lymph nodes here and from caudal to cranial, after exposing the vagus nerve and phrenic nerve on the scalenus muscles, consecutive development of the lateral neck preparation up to the accessorius triangle. Detachment of the same along the digastric muscle. Dissection of the submandibular gland, which is then deposited at the whartonian duct. The facial artery and facial vein are selectively dissected and spared. In the depth of the submandibular region (region Ib), removal of a conspicuous lymph node without capsular perforation. Careful hemostasis and dissection of the carotid bifurcation, especially the thyroid artery for subsequent vascularization. Now complete the ventral neck preparation and repeat hemostasis. Irrigation with H2O and repositioning for neck dissection on the left side: also here skin incision and dissection of the sternocleidomastoid muscle and, while preserving the accessorius nerve, the jugular vein, exposure of the hypoglossal nerve and here a modified radical neck dissection of levels II, III, IV and V is performed. Here too, meticulous hemostasis and completion of the procedure on the left side of the neck. Now horizontal skin incision for tracheotomy. Cut through the subcutaneous tissue to the infralaryngeal musculature, blunt, partly sharp cutting of the same and mobilization of the thyroid isthmus. This is undermined, grasped with 2 clamps and treated with a tobacco pouch suture after transection. The tracheal lumen is now opened between the 2nd and 3rd tracheal clasp. Formation of a Björk flap and transfer to a Rügheim cannula. Further ventilation is problem-free. Fixation of the cannula to the skin of the neck with 2 retaining threads. Now repositioning for tumor resection: After setting the tonsil stop, the tumor is now resected far into the healthy tissue with the electric knife, in some cases also sharply with the .................................... coagulation, initially from the anterior and posterior palatal arch, the cheek region is partly included and thus the tumor is resected far into the macroscopically healthy tissue. The tumor is detached from the hard palate with the freer, also from the mandible and traced further caudally into the depth of the lateral pharyngeal wall. Resection of the inner mandibular corticalis, which is sent with the tumor specimen. Now develop the entire tumor specimen transcervically and carefully stop the bleeding. Now take representative marginal samples from all 4 quadrants, which are found to be tumor-free in the frozen section assessment. Now reposition for radial artery flap harvesting: After abjuring and sterile draping, make an S-shaped incision from the antecubital region to the distal. Preparation of a skin graft corresponding to the defect and preservation of the same after preparation of a broad-lumen arterial connection and a venous drainage route. Inguinal skin harvesting: Spindle-shaped, adapted detachment of a full-thickness skin graft in the right inguinal region. Meticulous hemostasis and under slight tension, the primary wound closure is quite successful. A Redon drain is inserted beforehand. After irrigation with ............ solution of the graft, the forearm graft is subtly sutured into the defect. The superior thyroid artery is now dissected caudally transcervically and anastomosed to the arterial segment of the forearm flap. The venous segment is now connected with continuous suturing after selective ligation of several branches. There is very good perfusion without leakage. Intraoral control of the connected flap shows stable perfusion after pressure. In the meantime, long-term medication with the heparin perfusor is also started. Defect coverage of the forearm defect with the inguinal skin graft. Wound closure on both cervical sides after insertion of an 8-gauge Redon drain. After checking again that there is no bleeding in the flap area and perfusion, repositioning to remove a nasal atheroma: spindle-shaped skin incision with a skin spindle. Dissection of the subcutaneous tissue and removal of the atheroma in toto. Meticulous hemostasis using the above-mentioned skin spindle. In the absence of bleeding in the surgical area, wound closure with 5/0 Ethilon suture. Completion of the procedure after fixation of the tracheostoma on the cannula ligament. Check all drains. Patient is intubated and ventilated until morden in the intensive care unit. The patient received 250 mg SDH intraoperatively and intravenous antibiotics with Unacid 3 g were started.