First of all, after preparation by the anesthetist, pharyngoscopy and laryngoscopy again: The tumor is confirmed, which is located in the area of the uvula and also in the area of the palatal arch on both sides up to the tonsil border and also extends to the posterior wall of the palatal arch. Therefore, the indication for surgery and flap coverage is now confirmed. The tracheostomy follows: a horizontal incision is made approx. 5 cm 2 QF above the jugulum, sharply cutting through the skin, subcutaneous tissue and the platysma. The prelaryngeal musculature and the infrahyoid musculature are exposed, entered in the midline and the thyroid gland is exposed. Dissection of the trachea between the cricoid cartilage and isthmus. The isthmus is bipolarly dissected. No major bleeding. Between the 2nd and 3rd tracheal cartilage clasp, the trachea is entered and a visual tracheotomy is created without a Björk flap. The patient is intubated with an 8-gauge cannula. Completion of the procedure without complications. Subsequent PEG insertion: Start with insertion of the PEG tube. After entering the stomach and postoperative diaphanoscopy, the tube is inserted under visualization. This is performed without any problems. Application of a wound dressing. The tumor is now removed macroscopically with a safety margin of at least 1 to 1 1/2 cm on all sides. The entire tumor is marked with sutures. In addition, marginal sample of the pharynx caudal right and posterior palatal arch left. In the frozen section, both the specimen and the margin samples are healthy and free of carcinoma. Careful hemostasis. Repositioning for neck dissection: Neck dissection on the right (<CLINICIAN_NAME>, <CLINICIAN_NAME>): Skin incision in a curved incision on the anterior border of the sternocleidomastoid muscle from the mastoid to caudal at the level of the omohyoid. Sharp transection of the subcutaneous tissue and platysma. Exposure of the external jugular vein and transection. Elevation of the subplatysmal flap. Exposure of the submandibular gland, accessorius nerve, internal jugular vein and omohyoid muscle. There is a large metastasis in level II on the right side with infiltration of the sternocleidomastoid muscle and the lower branch of the accessorius nerve. After demonstrating the findings to <CLINICIAN_NAME>, the decision was made to perform a radical neck dissection and to resect the metastasis together with part of the sternocleidomastoid muscle and the lower branch of the accessory nerve. Dissection of the cervical vascular sheath is successful, the facial groove is also resected as it is drawn into the tumor. The neck specimen Ib to V is now removed, sparing the right cervical plexus. Two-layer wound closure with 4-0 Vicryl, platysma suture and skin suture with 5-0 Ethilon after placement of a 10-gauge Redon drain. Subsequent neck dissection on the left (<CLINICIAN_NAME>, <CLINICIAN_NAME>): Sharp dissection of the skin, subcutaneous tissue and platysma. Exposure of the external jugular vein, ligation and transection. Dissection of the anterior border of the sternocleidomastoid muscle, also here macroscopically palpation of several cervical metastases, these can be well dissected from the non-lymphatic structures. Thus, visualization of the omohyoid muscle, submandibular gland, accessory nerve, external carotid artery, internal carotid artery, internal jugular vein and removal of the neck preparation from level Ib to V. The left submandibular gland is also resected for the neck dissection. The digastric muscle is transected to enable the breakthrough. The superior thyroid artery is dissected and will later be used for the anastomosis. At this point, the patient is handed over to <CLINICIAN_NAME>, who performs the flap incision. Then removal of the forearm flap and elevation of the radial forearm flap on the left by <CLINICIAN_NAME> Palpatory identification of the distal radial artery. Marking of the flap borders (11 x 5 cm) on the distal forearm, proximal to the flexor retinaculum, with an S-shaped incision running proximally into the cubital fossa. Incision of cutaneous and subcutaneous tissue starting proximally. Identification and visualization of the venous confluence in the cubital fossa. Identification of the cephalic vein and dissection of the vein distally with integration into the radial graft margin. Identification of the ramus externus of the radial nerve and elevation of the radial portion, leaving the peritendineum of the tendons of the brachioradialis muscle intact. Subsequent ulnar incision down to the forearm fascia. Incision of the fascia and subsequent subfascial elevation of the ulnar edge of the graft up to the tendon of the flexor carpi radialis muscle. Care is taken to leave the peritendineum on the flexor tendons and to spare the ulnar artery. Identification of the distal radial artery and trial clamping with a vascular clamp. After 5 minutes with good oxygen saturation measured by pulse oximetry (measured on the index finger), the vessels are removed with subsequent ligation (Prolene 6.0). Successive detachment of the flap pedicle from the M. pronator quadratus and M. flexor pollicis longus with ligation of the outgoing perforators using a vessel clip into the cubital fossa. Exposure and protection of the radial nerve on the medial side of the brachioradialis muscle. Exposure of the brachial artery, V. mediana cubiti, A. ulnaris. First removal of the radial artery, then of two veins of the superficial venous system. Vascular ligation by means of a bypass ligature (artery) and vascular clip (veins). Subtle hemostasis in the area of the wound bed using bipolar coagulation forceps. Two-layer wound closure in the area of the proximal forearm. Covering of the graft bed with split skin from the right thigh in the usual manner. Suturing of preparation swabs. Application of a wound dressing and a forearm splint. Completion of the graft lift without complications. After suturing in the flap, the microvascular arterial anastomosis is performed by <CLINICIAN_NAME> in single-button sutures, whereby the radial artery is anastomosed to the superior artery on the left side. The venous anastomoses are performed using the Coupler technique by <CLINICIAN_NAME>. After performing the Coupler anastomosis of the veins, the ultrasound probe is placed to check the blood flow in the microvascular anastomosis. Then insertion of the flap: The submandibulectomy is performed first to create space for the tunnel on the left side in order to pull the stem of the flap through to the left side of the neck. For this purpose, submandibulectomy is performed in the typical manner, sparing the lingual nerve and hypoglossus. Subsequent transection of the digastric and styloid muscles with careful hemostasis. Creation of a 2-finger-wide tunnel above the residual tonsil on the left into the pharyngeal space. Then pull the stalk through after removing the flap. Cover the neck area moist. Suture the flap successively into the defect with 3-0 Vicryl single button sutures with complete defect coverage without tension. Subsequent creation of the vascular anastomoses. The arteries are anastomosed between the superior thyroid artery and radial artery using <CLINICIAN_NAME>. The veins are then sutured. After condensation of the vessels, the larger cephalic vein is anastomosed with the outlet of the facial vein near the internal jugular vein using a 3.5 mm coupler. After opening the clamps, smear phenomenon positive. Then suture the confluent vein with the inferior thyroid vein, also at the exit from the internal jugular vein, using a 2.0 mm coupler. Positive smear phenomenon even after opening the clamps, good flow. Then attach a Doppler probe in the area of the anastomosis of the cephalic vein with the facial nerve. The Doppler probe is fixed in the direction of the internal jugular vein proximal to the anastomosis using 2 sutures in the area of the silicone ring. After placing Gelita under the venous anastomosis, good venous perfusion signals can be derived. The probe is later removed from the wound slightly caudally in the planned direction of traction. Subsequent irrigation of the entire wound area and careful hemostasis on final inspection - no further evidence of bleeding. Insertion of 2 flaps on the left and a Redon drainage on the right and layered wound closure, also with epithelialization of the tracheostoma. Insertion of an 8 mm tracheostomy tube. Enoral flap vital on closure, Doppler probe signal stable. The patient is ventilated with a tracheostomy tube and transferred to the intensive care unit for monitoring. Please continue antibiotic treatment, which was started intraoperatively with Unacid, for one week. Feeding via the tube for approx. 10 days, then if necessary, depending on the situation, diet build-up. Monitor the flap clinically and also the Doppler signal for 5 days according to the scheme. Overall cT2-3 uvular carcinoma which was covered with radial flap. Intraoperative status at least cN2b, possibly also cN2c. Awaiting final histology and presentation at the interdisciplinary tumor conference.