After preparation, first place the PEG tube in the typical manner. Then perform the tracheotomy through <CLINICIAN_NAME> and <CLINICIAN_NAME> between the 2nd and 3rd tracheal cartilage. Re-intubation of the patient. Now first transoral tumor resection. After appropriate adjustment with the tonsil retractor, the tumor is resected with the monopolar caustic. Part of the soft palate on the left side or the uvula is resected. Laterally, the resection reaches the mandibular branch. Dorsally and medially, the tumor is successively resected in healthy muscle tissue. The resection continues into the glossotonsillar groove, which appears inconspicuous macroscopically. After removal of the tumor, peripheral incisions are made circumferentially, all of which are found to be tumor-free on frozen section histology. The selective neck dissection is then performed on the left side. After making the apron flap incision and dissection upwards, fixation upwards in the usual manner. Then skeletonize the sternocleidomastoid muscle. A large metastasis is found here in region II, which can be successively removed in toto after skeletonization of the digastric muscle. After opening and skeletonizing the vascular nerve sheath, regions I-V are resected while preserving all non-lymphatic structures. The large caliber jugular vein and the superior thyroid artery are skeletonized, exposed and preserved and are later used for anastomosis of the microvascular radial lobe graft. Subsequent transition to the opposite side. Here, after the initial start by <CLINICIAN_NAME>, the same procedure with similar findings. Here, too, there is a mass in region II, albeit a smaller one, which is suspected to be metastatic. The hypoglossal nerve is then exposed on the left side and cut upwards. Dissection of the digastric muscle and creation of the pharyngotomy at the caudal resection margin of the transoral resection. Widen the access while protecting the lingual artery, the external carotid artery and the hypoglossal nerve. Lifting of the radialis graft by <CLINICIAN_NAME>. Drawing of a graft in consultation with <CLINICIAN_NAME>, who measured the defect 9 x 6 cm. Marking of the radial artery, the ulnar artery and the cephalic vein. Then unwrap the arm and apply a 300 mmHg tourniquet. Incision of the skin and exposure of the brachioradialis muscle. Exposure of the cephalic vein which can be integrated laterally into the graft. Then expose the superficial ramus of the radial nerve. Preservation of this nerve branch with all its additional branches. Exposure of the radial artery. Separation of the radial artery, lifting of the graft from the tendon bed and preparation in the usual manner up to the elbow. The radialis graft is then removed, taking with it the cephalic vein from the superficial system and the venous confluence and lifting a venous outflow from the deep venous system. The graft is then flushed with heparin and handed over to <CLINICIAN_NAME>, who then sutures it in place. The defect is then covered with split skin from the right thigh in the usual way and the arm is closed in the usual way. The radial lobe graft is then inserted through the pharyngotomy into the resection defect. Fixation of the radial flap graft in the resection area. Subsequently, the microvascular anastomosis of the artery from the radial artery to the superior thyroid artery and the large-volume brachial vein to the facial vein is performed. The flap shows excellent perfusion on all sides. Application of a Redon drainage on both sides. Two-layer wound closure. Completion of the mucocutaneous anastomosis and transfer of the patient to an 8-gauge tracheostomy tube. Sterile wound dressing on both cervical sides. Transoral inspection of the flap from which bright red arterial blood runs out at the upper pole after puncture. End of the operation and transfer of the patient to anesthesia. Conclusion: partial oropharyngeal resection for tonsillar carcinoma on the left side. R0 resection on frozen section histology intraoperatively as well as macroscopically. Selective neck dissection on both sides. Defect coverage with microvascularly anastomosed radial artery flap graft from the left forearm and defect coverage on the left forearm with split skin from the right thigh. Arterial anastomosis to the superior thyroid vein and venous anastomosis to the facial vein. Creation of a PEG and a mucocutaneous tracheostoma. Intraoperative metastatic mass certainly on the left and also on the right, therefore adjuvant therapy is recommended postoperatively.