After intubation and preparation by the anesthesia colleagues, first inspection and palpation of the primary tumor area. An exulcerated tumor of the left base of the tongue was found, extending into the vallecula and occupying a good half of the base of the tongue, in contact with the epiglottis, extending over the lateral pharyngeal wall in the area of the caudal pole of the tonsil up to the entrance of the piriform sinus. Palpatory clear deep infiltration in the area of the base of the tongue. Due to the deep location of the tumor, indication for a primary transcervical approach. PEG insertion should be performed first. For this purpose, insertion with the gastroscope under laryngoscopic control. Easy pre-scanning into the stomach and, with good diaphanoscopy, easy puncture of the stomach and subsequent placement of the PEG tube using the usual thread pull-through method. After positioning the patient, start with the neck dissection on the left side. Submandibular skin incision here. Cut through skin and subcutaneous tissue as well as the platysma. Exposure of the sternocleidomastoid muscle, the omohyoid muscle, the submandibular gland and the digastric muscle. Clearing of the anterior neck preparation with careful protection of the superior thyroid artery, the cervical artery, the hypoglossal nerve and the facial vein. Level II shows a metastasis measuring approx. 3 cm in the area of the jugulo-facial angle, no surrounding infiltration, the accessorius nerve can be preserved. Clearing of the accessorius triangle and level V with careful protection of the cervical plexus branches. Subsequent resection of the digastric muscle. Exposure of the external carotid arteries and long exposure of the hypoglossal nerve. Release of the pharyngeal side wall against the carotid artery. Subsequent exposure of the hyoid. Entering the pharynx just below the epiglottis. Palpation reveals that the tumor is barely displaceable on the lingual surface of the epiglottis. Therefore resection of the cranial end of the epiglottis by approx. 2/3 of the width. Subtotal resection of the vallecula basally on all sides clearly in the healthy area. Subsequent resection of half of the base of the tongue. A clear safety margin is also maintained here. Resection of the pharyngeal side wall and thus macroscopic in sano removal of the tumor. Macroscopically narrowest point in the area of the pharyngeal side wall, otherwise extensive resection and clear resection distance to the depth on all sides. In the area of the pharyngeal side wall, a marginal specimen is therefore completely imaged in the pharyngeal area. The remaining marginal samples are then removed from the specimen, completely covering it. CIS with a questionable microinvasive component can still be seen in the area of the pharyngeal side wall in otherwise completely tumor- and dysplasia-free marginal samples. Therefore, a resection is performed in the entire area followed by imaging of a marginal sample, which is diagnosed as completely free of dysplasia and tumor. Therefore an overall R0 situation. Measurement of the defect. A defect measuring a total of 12 x 7 cm was found, which extended from the soft palate to the entrance of the piriform sinus, with removal of the vallecula and half of the base of the tongue. The rest of the tongue is regular and well supplied with blood. Turn to the neck dissection of the right side. In principle the same procedure as on the opposite side. Submandibular incision. After cutting through the skin and subcutaneous tissue, expose the bordering muscles. Clear the anterior neck preparation while carefully protecting the superior thyroid artery, the cervical artery and the facial vein. Free preparation of the internal jugular vein. Clearing of the accessorius triangle while carefully protecting the nerve. Subsequent evacuation of level V with careful protection of the cervical plexus branches. This also revealed a clearly suspicious change measuring a good 2.5 cm in the jugulo-facial angle, confirming the overall cN2c neck status. On the opposite side, a metastasis-specific lesion was also removed in toto in the soft tissue on the way to tumor resection. This is followed by careful wound irrigation and, if the wound is dry, insertion of a 10 Redon drain and careful, two-layer wound closure. The plastic tracheostomy is then performed. Horizontal incision below the cricoid cartilage. Cutting through skin and subcutaneous tissue. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. After cutting through the thyroid isthmus, enter between the 1st and 2nd tracheal ring. Perform a visor tracheotomy and suture the trachea to the skin level. Subsequently, easy transfer to a size 8 low-cuff cannula, which is suture-fixed. The radialis graft is then removed from the left forearm. After applying the tourniquet, mark the graft measuring 12 x 7.5 cm in total. Radial exposure of the brachioradialis muscle. Exposure and protection of the superficial radial nerve ramus. Exposure of the distal vascular pedicle and transection of the vascular pedicle. Ulnar dissection of the flexor carpi ulnaris. Strictly subfascial release. Making the extension incision. The cephalic vein lies far dorsally and is therefore not elevated. Stalk preparation in the crook of the elbow. Expose and secure the outlet of the ulnar artery and the common interosseous artery. Exposure of a venous confluence. Subsequent reopening of the tourniquet. Vital graft. Regular blood supply to the hand. Careful hemostasis of the graft and the forearm and removal of the vital graft after ligation and clipping of the supplying vessels. The wound is then closed in two layers in the arm area and the full-thickness skin graft harvested from the groin is then incorporated. This is followed by treatment with a vacuum sealing bandage and application of the Kramer splint in the functional position and repositioning of the arm. To lift the full-thickness skin from the groin on the right. Incision of a piece of skin measuring approx. 14 x 6.5 cm. Strictly cutaneous lifting. Subcutaneous mobilization. Careful hemostasis. Insertion of a 10-gauge Redon drain and careful, two-layer wound closure under moderate tension. Subsequent transcervical insertion of the graft. Overall good fit and intact conditions on all sides. Conditioning of the superior thyroid artery. Perform the arterial anastomosis with 8-0 Ethilon. Immediate correct pedicle position and venous return. Measure a coupler size 3.0 and perform the venous anastomosis with the facial vein using the coupler system. Subsequently, proper graft perfusion and proper pedicle position with positive spreading phenomenon. This is followed by careful wound irrigation, insertion of a 10 Redon drain and careful, two-layer wound closure. Final inspection and completion of the procedure with a vital graft.