First insertion of the PEG tube. For this, insertion with the gastroscope under laryngoscopic control. Easy pre-scanning into the stomach. Here, with good diaphanoscopy, problem-free puncture of the stomach and subsequent placement of the PEG tube using the usual thread pull-through method. Regular esophagus on reflection. Inspection and palpation are now performed. There is a coarse tumor limited to the left tonsil, but with a clearly submucosal part. Exposure with the tonsil retractor. Mucosal incision as for tumor tonsillectomy. It quickly becomes apparent that the tumor clearly infiltrates the muscles of the posterior palatal arch submucosally. After removal of the anterior palatal arch, the tumor can be seen growing in depth per continuitatem into the soft tissues of the neck and on cervical palpation with direct adhesion to the lymph node metastasis. Complete detachment from the mucosal level, this is covered with marginal samples, which are later classified as tumor-free. Now repositioning for neck dissection of the left side. Injection of xylocaine with added adrenaline, cutting of skin and subcutaneous tissue. Separation of the external jugular vein. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. It is palpable that the metastasis in the upper part infiltrates the sternocleidomastoid muscle. Visualization of the submandibular gland and the digastric muscle. This shows that the posterior venter is also infiltrated. Therefore, the sternocleidomastoid muscle is now exposed caudally. Exposure of the internal jugular vein. This shows that it is completely infiltrated and occluded from approx. level III, therefore the vein is removed caudally. Exposure of the common carotid artery and vagus nerve en bloc. Dissection of the markedly hard metastasis which firmly infiltrates the surrounding area, taking level V with it. The cervical plexus must be taken subtotally. Cranially, the metastasis can be seen growing ever closer to the spinal column. In the area of the spine, the metastasis can be resected in sano, taking the musculature with it. Extirpation of the submandibular gland and the digastric muscle. Removal of the muscular pharyngeal side wall and thus resection of the tumor with the ..............., which is located directly at the metastasis as described above. Resection with absolute infiltration of the hypoglossal nerve. After complete removal, it is now clear that the tumor surrounds the carotid bulb as well as the external and internal carotid arteries by almost 360°. After visualization, there is a clear infiltration of the carotid bulb and the internal carotid artery. Now add <CLINICIAN_NAME>. Confirmation of the findings. The tumor is now debulked as far as possible. Deposition of the external carotid artery close to the bulb. The internal carotid artery can now be freed from the tumor over a long distance. In the case of bulbar infiltration, extremely vulnerable conditions, new vascular suture required here, therefore no further measures here so that an overall R2 situation remains at the carotid bulb after complete resection. Due to the overall situation, the indication for defect coverage and vascular protection using a pectoralis major flap is now given. Lifting of the pectoralis major flap (<CLINICIAN_NAME>): First draw in the deltopectoral flap and the skin island. The skin island is 8 x 10 cm in size. In consultation with <CLINICIAN_NAME>, cut around the skin island, then cut through a very thick layer of fat. Dissection down to the musculature. Then removal of the pectoralis major muscle from the chest wall, partly sharp, partly blunt. Blunt exposure of the pectoralis minor muscle and exposure of the vascular pedicle. This is successful without any problems. Then create a tunnel in the area of the deltopectoral flap while protecting the fascia of the pectoralis major muscle. Then cut through the pectoralis major muscle lateral and medial to the vascular pedicle. This must be done as far up as possible, as the flap must extend into the tonsil region and the defect is relatively large and there is also a large subcutaneous fat layer. Sutures are then placed in the caudal region. Pulling through the pectoralis major flap and fixation in the cranial region from the enoral side. The remaining suture fixation from transcervical. The flap was vital and supplied with blood until the end of the operation. Redon drains were then inserted and the skin was sutured in 2 or 3 layers, also in the chest area. Unfortunately, the wound in the neck area cannot be completely closed, as otherwise pressure would have to be applied to the vascular pedicle. Therefore, full-thickness skin was removed from the excess skin on the breast, meshed and covered the open defect with meshed full-thickness skin. Unfortunately, this is not completely sufficient, so that the remaining part of the secondary granulation must be left in place.