Initially start with PEG insertion: For this purpose, insertion with the flexible gastroscope under laryngoscopic control. Easy pre-scanning into the stomach. If diaphanoscopy is very good, regular puncture of the stomach and insertion of the PEG using the usual thread pull-through method. This is successful without any problems. Inconspicuous esophageal mucosa on reflection. Now insertion of the tonsil plug and inspection of the primary tumor region. Previously, palpation revealed a circumscribed induration of the right base of the tongue, but no more extensive infiltration. Inspection now revealed an exulcerated mass in the right tonsil region. From this exophytic mass, extensive erythroplakic changes extend towards the hard palate and parauvularly on the right, also in the area of the upper and lower alveolar ridge; in addition, extensions over the glossotonsillar groove towards the base of the tongue. In the area of the base of the tongue, there were renewed restless, exophytic changes, but not deeper on palpation. The tumor is now resected, partly monopolar, partly using the dissection technique. Left parauvular incision, taking the entire right-sided soft palate as far as the hard palate. Resection alveolar above, hard to the molars. Resection down to the alveolar ridge. Resection of the glossotonsillar groove and superficial resection of a good 1/3 of the base of the tongue. Removal of the tonsil region up to the transition to the posterior pharyngeal wall. Tumor extension towards the posterior pharyngeal wall is not visible. The specimen is completely thread-marked for frozen section diagnostics. CIS in the area of the hard palate towards the alveolar ridge and buccal direction as well as CIS in the parauvular area in the area of the soft palate with otherwise free tumor margins and free basal margins are now visible. Post-resections are now performed in the respective areas, which are again marked with sutures for frozen section diagnostics. This again reveals CIS in the area of the alveolar ridge. Now perform another generous resection from the upper alveolar ridge over the entire buccal length to the lower alveolar ridge. A marginal sample is then taken over the same length, which is again marked with a suture for frozen section diagnostics and this time is assessed as tumor-free. Parallel to the tumor resection, a waisted graft measuring 13 x 6 cm is measured. Parallel procedure for neck dissection and tracheotomy: First tracheotomy. Horizontal skin incision below the cricoid cartilage. Cut through the subcutaneous tissue. Exposure of the infrahyoid musculature. Cut through. Exposure of the cricoid cartilage and the anterior surface of the trachea. Exposure of the thyroid isthmus. Dissection and clamping and transection of the thyroid isthmus. Further exposure of the anterior surface of the trachea. Insertion between the 2nd and 3rd tracheal ring. Creation of a Björk flap with a broad-based stalk and suturing of the mucocutaneous anastomosis. Subsequent easy transfer to a tracheal tube. Then turn to neck dissection on the right: This is a condition following an unclear neck operation. Curved skin incision on the anterior edge of the sternocleidomastoid muscle. Pronounced scarring in the area of the previous operation. An external jugular vein can no longer be visualized here. Dissection of the subcutis and the platysma. Exposure of the sternocleidomastoid muscle. If there is significant cranial scarring, it is difficult to expose the accessorius nerve. Exposure of the omohyoid and digastric muscles. Free preparation and exposure of the internal jugular vein with cervical vein. A very strong facial vein can be seen, which is preserved. Exposure of the submandibular gland. Exposure of the superior thyroid artery and hypoglossal nerve. Now careful clearing of the accessory triangle. Exposure of the common carotid artery and vagus nerve and careful evacuation of level Vb while carefully preserving the plexus branches. All the structures mentioned were preserved during this procedure. Macroscopically, no suspicious lymph nodes were found. Later, the submandibular gland was extirpated. For this purpose, the gland is peeled out subcapsularly while carefully preserving the branch of the mouth. Detachment of the uncinate process and removal after transection of the duct. Now perform a partly blunt, partly preparatory pharyngotomy, approx. 2 transverse fingers wide. This is successful due to the already enoral resection. Now to lift the radialis graft from the left: After marking the graft, unwrap the arm and apply the tourniquet. Cutting around the graft and skin incision with lifting of a skin monitor. With a 13 cm long graft, relatively short distance between graft and monitor to maintain a largely flexible stem length. Now expose the cephalic vein. Follow and perform the Hayden maneuver and expose the superficial radial nerve ramus. Complete preservation of the nerve. After preservation of the nerve, strictly subfascial dissection and release of the radial portion of the flap. Now elevation further from the ulna. Strictly subfascial dissection. A superficial ulnar route is not visible. Identification and careful protection of the median nerve. Further strictly subfascial dissection with clipping of vessels close to the pedicle. This is successful without any problems. A strong fork between the cephalic vein and the strong cubital branch can be visualized in the antecubital region. After dissection of the pedicle, a clear anastomosis between the deep and superficial venous system can be visualized. Exposure and protection of the interosseous route. Reopening of the tourniquet. Immediate regular, somewhat hyperemic reperfusion of the flap with good perfusion of the skin monitor. Minutious hemostasis using clipping and bipolar coagulation. Now initially warming of the arm and the graft with simultaneous post-resection. Neck dissection is also performed on the left side. To do this, make a curved skin incision from the mastoid over the front edge of the sternocleidomastoid muscle. Cut through the subcutis. Exposure and transection of the platysma. Creation of a platysma flap. An external jugular vein cannot be exposed here. Exposure and sparing of the auricular nerve. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Exposure of the submandibular gland and the digastric muscle. Evacuation of the anterior neck preparation with visualization and preservation of the cervical anus, artery and superior thyroid vein. Palpatory identification of the accessorius nerve. After exposing the cervical artery, expose the internal jugular vein. Free dissection reveals an internal jugular vein, which is double-lumened over a distance of approx. 4 cm. Here, branched inlets and a tear of an internal vessel are circumscribed. Vascular suture with 6.0 prolene. This succeeds without any problems. Further visualization. The internal jugular vein reunites approximately at the level of the hyoid and gives off a short but very strong facial branch anteriorly. Now follow the cervical vein posteriorly. Expose the common carotid artery and the vagus nerve. Protect the structures. Successive evacuation of level V while carefully protecting the plexus branches. Clearing of the accessory triangle after nerve exposure. Exposure and preservation of the accessorius............ Final inspection and, if the wound was dry, insertion of a 10-gauge Redon drain and careful, two-layer wound closure. On the left side, there were macroscopically conspicuous lymph nodes in level IV and V. All these structures could be preserved. The vital graft was then removed and the radial flap was incorporated. For this purpose, traction from transcervical. Successive and relatively laborious incorporation with a strong radialis graft. This is sufficient in length. Finally, good fit, only in the area of the upper alveolar ridge there is an overlapping of the posterior molar by the graft due to the resections close to the mucosa, which cannot be completely prevented despite several attempts at suturing and repositioning. Otherwise good graft fit. Parallel to suturing, full-thickness skin was removed from the groin region on the right. A spindle-shaped graft measuring 14 x 7 cm was harvested for this purpose. Subcutaneous mobilization and, after insertion of a 10 Redon drain, multi-layer wound closure, which was successful under moderate, tension-free conditions. Cleaning of the graft and careful incorporation after two-layer wound closure of the forearm in the area of the lifting defect. If the fit is good, a VAC dressing is then applied. Finally, turn to the vascular anastomosis. Exposure and free preparation of the superior thyroid artery. Slightly more difficult positioning conditions in the area of the vascular pedicle, otherwise problem-free arterial anastomosis with 8.0 Ethilon. With good reflux, preparation of a facial branch equivalent to a vein. After vessel preparation with very good reflux, problem-free venous anastomosis with a size III coupler. This was successful without any problems. Good reflux and regular flap and monitor perfusion. Now vessel positioning to protect against kinking. Careful wound inspection and finally meticulous hemostasis. Insertion of a 10-gauge Redon drain with countersunk suture to protect the vascular pedicle and, after monitor adjustment, successive, careful two-layer wound closure and finally reintubation onto an 8-gauge cannula with inner core, which is sutured in place and the procedure is completed at this point without any indication of complications. Conclusion: After frozen section diagnosis R0-resected cT3 oropharyngeal carcinoma on the right. Postoperatively, please monitor closely and regularly. Please monitor the findings in the area of the upper alveolar ridge. Post-operative X-ray pelvis recommended on the 8th postoperative day. If possible, the cannula should be left in place and sutured for 5 days.