Induction of anesthesia by anesthesia colleagues. Intubation transnasally by the anesthesia colleagues. Sterile washing and draping. First inspection of the tumor region. The tumor is located in the area of the left edge of the tongue, extends to the base of the tongue and infiltrates two thirds of the tongue, especially in the base of the tongue area, extends to the floor of the mouth as well as to the soft palate and the tonsil region and oropharyngeal side wall on the left. The tumor is first resected transorally, in the area of the edge of the tongue and the floor of the mouth. The tumor must then be moved transcervically, as there is no longer an adequate overview. To do this, make a skin incision 2.5 transverse fingers below the lower jaw in a skin fold. Expose the platysma. Separation of the platysma. Perform the neck dissection on the left in levels II a to V a. Form a platysmal flap cranially and caudally. Exposure of the sternocleidomastoid muscle, the omohyoid muscle, the cervical vascular sheath and the submandibular gland. Locating and exposing the nervus accessorius and free preparation of the internal jugular vein and facial vein. Clearing out the neck levels II a to V a, while sparing the plexus branches. Level II contains several enlarged metastases that are resected en bloc. Exposure of the vessels, in particular the lingual artery and the superior thyroid artery. The arterial vessels themselves are quite narrow and have an encrusted arterial wall. Continuation of the tumor resection. To do this, remove the submandibular gland and cut through the digastric muscle. This automatically leads to the area of the oral cavity. The tumor can now be further resected from the transcervical area and finally removed transcervically using the pull-through technique. This results in a very large pharyngeal defect and at least two thirds of the tongue is removed at the base of the tongue. The lingual nerve and the lingual artery can no longer be spared on the left side, but are completely present on the right side. Neck dissection on the right by <CLINICIAN_NAME> and parallel lifting of the radialis graft. Neck dissection right level II a to V a. Skin incision in a transverse skin fold 2.5 cm below the mandibular branch. Exposure of the platysma. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle, the submandibular gland and the cervical vascular sheath. Exposure of the digastric muscle. Dissection of the jugular vein. Exposure of the vagus nerve and the accessorius nerve. Clearing of neck levels II a to V a, while sparing the plexus branches. Several lymph nodes are removed, which do not look suspicious on all sides. Insertion of a Redon drain and two-layer wound closure. Lifting of the radialis graft. First marking of the graft. Applying the tourniquet and cutting around the graft. Exposure of the brachioradialis muscle. Exposure of the cephalic vein and the vein star in the crook of the elbow. Then expose the superficial ramus, the radial nerve and its subdivision. All branches can be spared. Exposure of the radial artery with the accompanying vessels. Ligation and transection of the radial artery. Detachment of the graft from the tendon bed and preparation of the pedicle up to the crook of the elbow. A vein is lifted from the superficial system and a vein including the venous confluence from the deep system. Deposition of the graft and suturing of the forearm in the usual manner. Split skin was taken from the right thigh to cover the defect on the forearm and covered using a compress and swab suturing technique. A dorsal forearm splint was applied and the arm attached. In the meantime, the graft is fitted three-dimensionally into the defect. Suturing is extremely difficult due to the small mouth opening and the severe swelling. Ultimately, the graft is successfully fitted in such a way that both the soft palate and the floor of the mouth are reconstructed and the base of the tongue, the edge of the tongue and the side wall of the oropharynx are reconstructed using the same graft and a special folding technique. Now turn to the vascular anastomosis. First attempt to connect the arterial anastomosis to the stump of the lingual artery. This is initially successful and the venous anastomoses are also couplerized in the usual manner, however, due to the high catecholamine consumption caused by the anaesthesia, spasticity occurs in the arterial region, so that even after repeated irrigation and waiting, there is no longer any arterial perfusion in the graft area. The arterial anastomosis is therefore opened and it becomes clear that the lingual artery in the donor area is completely spastic and there is no longer sufficient blood flow. Therefore, the lingual artery is ligated and the superior thyroid artery is exposed and prepared. This is now connected to the radial artery so that sufficient transplant perfusion can ultimately be achieved under difficult circumstances. Insertion of a Redon drain and two-layer wound closure and completion of the procedure. The patient goes to the intensive care unit intubated and ventilated. Please continue antibiotics for 24 hours and 500 units of heparin per hour for 5 days due to the difficult anastomosis conditions. Flap checks according to the usual schedule and presentation of the patient to the tumor conference after receipt of the histology.