First, pharyngoscopy and laryngoscopy again: The exulcerated tumor is seen in the area of the edge and body of the tongue on the right, the tip of the tongue is recessed, palpation extends into the base of the tongue, does not cross the midline and merges slightly into the floor of the mouth. Overall, indication for the above-mentioned operation with flap coverage confirmed. Initial PEG insertion: Pre-mirroring with the gastroesophagoscope and insertion of the PEG tube using the thread pull-through method after a clear positive diaphanoscopy. No complications. Subsequent transoral tumor resection: insertion of Spandex, followed by insertion of a retractor to open the mouth. Snaring of the tongue. Subsequent resection of the tumor with a safety margin of at least 1.5 cm macroscopically to 2 cm macroscopically on all sides. The right half of the tongue is removed, leaving out the most anterior parts of the tip of the tongue. Resection is performed next to the left raphe. Resection encompasses the floor of the mouth up to the alveolar ridge, taking all soft tissue down to the bone. The lingual nerve cannot be spared here and is also resected, as are parts of the sublingual gland and submandibular gland. Resection extends to the base of the tongue. The resection extends from the alveolar ridge over the anterior palatal arch to the right tonsil, which is also taken along with the anterior palatal arch. The specimen is then removed in toto and marked with sutures. It goes to the frozen section examination. In addition, the submandibular gland with attached soft tissue is removed transcervically and an extensive resection or marginal sample is taken from the soft tissue basally at the transition to the neck on the right. In combination with the main tumor and marginal samples, this results in an R0 situation. Subsequent careful hemostasis. Measure the size of the flap, which is approx. 12 x 8 cm. Drawing in three-dimensional requirements on the left forearm. Neck dissection on the left by <CLINICIAN_NAME>/<CLINICIAN_NAME>: Incision on the anterior edge of the sternocleidomastoid muscle between the mastoid and 2 transverse fingers above the clavicle using a 10 mm scalpel. Sharp cutting of the skin, subcutaneous tissue, platysma. Ligation and transection of the external jugular vein. Exposure of the anterior border of the sternocleidomastoid muscle. Exposure of the omohyoid, digaster and submandibular gland on the left. Exposure of the accessorius nerve, which shows an anastomosis to the cervical plexus. The internal jugular vein, hypoglossal nerve, common carotid artery and vagus nerve are now also visualized and the neck preparation is successively replaced, starting with level II up to level V b. Macroscopically, several metastases requiring partial removal of the cervical plexus. The accessor nerve remains intact as well as the anastomosis to the cervical plexus. Level V b is also completely removed. No chyle fistula. Punctual hemostasis. Insertion of a 10-gauge Redon drain and two-layer wound closure using 3.0 Vicryl and 4.0 Ethilon. Neck dissection on the right by <CLINICIAN_NAME>: Incision on the anterior edge of the sternocleidomastoid muscle between the mastoid and 2 transverse fingers above the clavicle using a 10 mm scalpel. Sharp cutting of the skin, subcutaneous tissue, platysma. Ligation and transection of the external jugular vein. Exposure of the anterior border of the sternocleidomastoid muscle. Exposure of the omohyoid muscle, the V. post of the digaster muscle and the left submandibular gland. Visualization of the accessorius nerve, which shows an anastomosis to the cervical plexus. Macroscopically, there are several metastatic masses. The largest in level II on the jugulofacial angle. This is successively replaced by the VJI and the facial vein. The hypoglossal nerve and the two veins can be spared. The common carotid artery and vagus nerve are now also visualized and the neck preparation is successively detached starting with level II up to level Vb. The accessory nerve remains intact as well as the anastomosis to the cervical plexus. Level V b is also completely removed. No evidence of chyle fistula. Punctual hemostasis using bipolar coagulation. Submadibulectomy and removal of the lymph nodes of level Ib in toto. Now transection of the digastric muscle V. postior and breakthrough enorally. Exposure of the superior thyroid artery, the lingual artery and the facial artery as possible connecting vessels. Elevation of the radial forearm flap on the left by <CLINICIAN_NAME> and <CLINICIAN_NAME>: Palpatory identification of the distal radial artery. Marking of the flap borders (12 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 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. 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. Removal of split skin from the right thigh and two-layer closure of the left forearm by <CLINICIAN_NAME>. Then suturing of the flap. The flap is sutured successively, partly with the sutures in place, and the pedicle is pulled through in between. It can be seen that the flap can be sutured into the defect correctly in three dimensions without tension and without any problems. Subsequent vascular anastomoses. The radial artery is anastomosed with the superior thyroid artery after vessel conditioning using 9.0 Ethilon single-button sutures. After conditioning of a thyroid vein and a facial vein, the vein is sutured with 3.0 and 2.5 mm couplers in the typical manner. In each case after opening the clamps, smear phenomenon positive and good venous return, also good arterial flow. Subsequent careful irrigation. Layered closure of the neck wound on the right with insertion of 2 flaps and on the left with insertion of a Redon drain. Finally, tracheostoma placement by <CLINICIAN_NAME>: skin incision and dissection through the subcutaneous fatty tissue. Dissection along the linea alba in depth. Push the infrahyoid muscles to the side. Exposure of the thyroid gland and ligation of the V. jugularis ant. Untermination and transection of the thyroid gland. Exposure of the front of the trachea. Insertion between the 2nd and 3rd tracheal clasp in the form of a visor tracheotomy. Suturing in the usual manner. Thorough inspection of the flap. This is well supplied with blood. The procedure is then completed without complications. Patient goes to the intensive care unit for monitoring. Flap control routinely for 5 days by means of enoral inspection. Postoperative continuation of antibiotics as already started preoperatively with Unacid i.v., feeding via the inserted PEG tube for 10-12 days, then gruel swallowing and, if necessary, diet build-up. Overall cT3 cN2c tongue carcinoma or oropharyngeal carcinoma on the right. Awaiting final histology and discussion of further procedure in the interdisciplinary tumor conference.