After preparing and positioning the patient, the PEG is first inserted. Insertion with the gastroscope under laryngoscopic control. Easy pre-laryngoscopy into the stomach. Excellent diaphanoscopy, problem-free puncture of the stomach and insertion of the PEG tube using the usual thread pull-through method. Then careful positioning with moderate hyperextension, starting with transoral tumor resection. First perform pharyngoscopy. An exophytic, exulcerous tumor is seen in the right paramedian soft palate. This infiltrates the soft palate completely. Only small remnants on the left side, growth into the soft palate dorsally. However, no dorsal mucosal perforation. On the right side, circumscribed infiltration of the upper tonsil pole and the posterior palatal arch. Otherwise, no further extension by palpation and inspection. The tumor is now resected with a macroscopic safety margin of approx. 1.5 cm. Resection of the tumor macroscopically clearly in toto. When releasing the soft palate, good control of the posterior surface is also possible, here too maintaining the safety distance. Isolation to the upper tonsil pole, subtotal removal of the anterior palatal arch. Partial resection of the posterior palatal arch. This safely resects the carcinoma. If the upper pole of the tonsil is infiltrated, the tonsillectomy is performed using the classic dissection technique. Removal of the tonsil at the lower tonsil pole. Certainly no tumor growth here. The tumor is sent as a thread-marked specimen for frozen section diagnostics and is diagnosed here as a squamous cell carcinoma resected in sano. The result was an almost total soft palate defect with a defect in the area of the tonsil lobe, therefore a graft defect measuring up to 10 x 6 cm was measured. Multiple checks and, in the event of blood dryness, initially turning to neck dissection on the left side. A very short neck is seen. Difficult visualization conditions due to lack of hyperextensibility with short anatomical relationships. Skin incision submandibularly and at the anterior edge of the sternocleidomastoid muscle, cutting through skin and subcutaneous tissue. Exposure and dissection of the platysma. Creation of a platysma flap. Exposure and later ligation of the external jugular vein with a very oblique course. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle, the submandibular gland and the digastric muscle. Release of the anterior neck preparation with careful protection of the cervical artery, the superior thyroid artery and the hypoglossal nerve. Exposure of the internal jugular vein. Careful free preparation. Level 2 shows a slightly enlarged but non-adherent lymph node measuring approx. 2 x 1 cm in the area of the jugulo-facial angle. Exposure of the accessorius nerve. Evacuation of the accessorius triangle with careful protection of the nerve and evacuation of level 5 with careful protection of the cervical plexus branches and caudal protection of the lymph vessel structures. Final inspection. In dry conditions after resection of the neck dissection en bloc. In dry conditions, insertion of a 10-gauge Redon drain and careful two-layer wound closure. Repositioning and parallel neck dissection of the right side and elevation of the radialis graft from the left forearm. First turn to the neck dissection. Correspondingly to the opposite side, make the skin incision. Cut through skin and subcutaneous tissue. Exposure of a distal part of the strong external jugular vein, which tapers significantly towards the submandibular region. Preservation of the vessel. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Exposure of the submandibular gland and the digastric muscle. The anterior region shows clear scarring in this case following transcervical cervical spine surgery. Release of the anterior neck preparation with careful protection of a deep facial vein branch. Exposure of the very slender superior thyroid artery. Exposure of the hypoglossal nerve and the cervical artery. Dissection of the internal jugular vein. Several macroscopically enlarged lymph nodes are visible in levels 2 and 3. Also non-adherent visualization of the accessorius nerve. Release of the accessorius triangle with careful protection of the nerve and release of level 5 with careful protection of the cervical plexus structures. Overall, difficult preparation conditions on both sides due to the anatomical conditions and the difficult positioning. After careful inspection with dry wound conditions, the digastric muscle is resected. Exposure of the carotid bulb and the division of the carotid artery. Exposure of the external carotid artery with the superior thyroid artery, facial artery and occipital artery. Cranial dissection along the artery. Exposure of the styloid under enoral inspection. Performing the pharyngotomy in the area of the tonsil lobe on the right. Widening of the pharyngotomy under control of the vascular nerve structures. However, creation of a tunnel a good two transverse fingers wide. Subsequent insertion of the radialis graft without any problems. To lift the radialis graft. After marking the graft with a special soft palate configuration. Perform the tourniquet. Cut around the graft. Exposure of the brachioradialis muscle, a right constant cephalic vein does not exist here. Expose, secure and protect the superficial radial nerve ramus. Exposure of the distal vascular pedicle. Deposition after ligation, strictly subfascial release. Exposure of the flexor carpi ulnar. Strictly subfascial dissection with clipping of outgoing vessels. After complete elevation of the graft, isolate the vascular pedicle. A relatively stable larger vein can be visualized in the cranial part of the graft. This is dissected proximally to the specimen and opens into the cupital vein. There is a strong bridge between the accompanying veins of the radial artery and the cupital system, which is why the vein is included. The very slender anterior interosseous artery must be clipped. Securing the ulnar artery. A very strong vessel here. Isolate the graft on a strong cupital vein and the radial artery. Reopening of the tourniquet. Immediate regular graft and hand perfusion. Meticulous hemostasis and, after removal of the graft, removal of the full-thickness skin graft from the groin and careful two-layer wound closure. A vacuum sealing dressing is then applied and the stretcher splint is placed in the functional position. For full-thickness skin harvesting from the left groin. For this purpose, cutting of a 12 x 6 cm full-thickness skin graft with strict cutaneous elevation. Subcutaneous undermining and mobilization and strong multi-layer wound closure under moderate tension after insertion of a 10 Redon drain. Now turn to the insertion of the graft. After placing sutures in the area of the dorsal soft palate and towards the nasopharynx, insertion of the graft. The situation here is somewhat difficult with a relatively thick subcutaneous fat layer. Overall, however, a good fit. Complete coverage of the tonsil lobe and the soft palate defect. If the conditions are intact, turn to the vascular anastomosis. Conditioning of the graft vessels. In comparison, the artery is most likely to be equivalent in caliber to the facial artery. Therefore preparation of the vessel. Deposition after clipping. Careful conditioning of the facial artery and somewhat more difficult with a relatively small vessel, but finally good and sufficient anastomosis with 8.0 Ethilon. After reopening, immediate venous return and regular graft perfusion. Due to the positioning, the caudally very strong external jugular vein appears to be well suited for conditioning the vein cranial clipping, there is good flow on the vein, therefore preparation for anastomosis. Measurement of a size 4.0 coupler and problem-free performance of the venous anastomosis with the coupler system. After reopening the clamps, immediate regular graft perfusion and regular pedicle pulsation. After checking the wound, insertion of a 10 Redon drain. Splinting of the drainage with 3.0 Vicryl and careful two-layer wound closure. Multiple enoral inspections of the graft and, in the case of regular vitality with slim enoral conditions, no tracheotomy and completion of the procedure after the patient had been repositioned without any indication of complications. Conclusion: Intraoperative R0 resected cT2 oral cavity carcinoma intraoperative reactive lymphadenopathy differential diagnosis cN+ neck status. Depending on the histological findings, planning of adjuvant therapy if necessary. Postoperative meticulous flap monitoring by enoral inspection. Avoidance of pressure dressings, especially on the right cervical side in the case of vein anastomization to the external jugular vein. The patient received intraoperative i.V. antibiotics with Sobelin 600 mg for penicillin allergy; please continue this for 24 hours postoperatively. If the graft heals properly, a gradual diet can be started from the 8th postoperative day.