Transfer of the patient to the operating theater. Introductory consultation with anesthesia colleagues. Carrying out the team time-out. Induction of intubation anesthesia by colleagues. Nasal intubation and fixation of the tube by the anesthesia colleagues. Start of the operation using hypopharyngo- and laryngoscopy. No abnormalities were found. The piriform sinus, postcricoid region and the entire larynx are unremarkable. Inspection of the base of the tongue without any abnormalities. Now insertion of the Jennings mouth retractor and inspection of the oropharynx. Here, an ulcerous mass is seen on the ascending mandibular branch extending to the tonsillar lobe and the glossotonsillar groove. The tumor continues to spread anteriorly along the mucosa of the alveolar ridge. Overall, the tumor extends to the first premolar of the mandible on the left. Upwards, the tumor merges slightly into the anterior palatal arch. The posterior palatal arch and the nasopharynx are free. In particular, no tumor spread along the uvula. Initially transoral tumor resection. The tumor is visible in the region described. This is successively resected macroscopically on all sides with a safety margin of 0.5 to 1 cm. The entire anterior palatal arch with tonsil, part of the base of the tongue and glossoalveolar groove, posterior part of the floor of the mouth and the entire mucosa in the alveolar ridge are resected dorsally. The remaining molar here is also extracted and fixed to the specimen for histological examination. The preparation is thread-marked. A marginal sample is taken from the area from the palatal arch to the alveolar ridge at the front as a lateral marginal sample and a further marginal sample from the posterior floor of the mouth. According to pathology, the tumor is relatively close to the upper superior margin and basally lateral. Therefore, again removal of marginal samples from the uvula and from the superior palatal arch, as well as extensive resection of the basal medial soft tissues, whereby the previously preserved lingual nerve is also resected, as it lies in the expected area of the tumor remnants. The entire periosteum of the mandible is also resected medially. There are no more tumor infiltrates in the entire specimen, so the resection is now R0. Extensive re-drilling of the medial alveolar ridge border and the alveoli follows. Subsequent irrigation with Ringer's solution with hydrogen and careful hemostasis. Swab insertion. Repositioning for neck dissection on the left: Here incision in typical manner. Exposure of the sternocleidomastoid muscle. Exposure of V. facialis, V. jugularis externa, V. jugularis interna, V. thyroida media, A. carotis interna and externa. Exposure of the accessory nerve, hypoglossal nerve and vagus nerve. Subsequent evacuation level II to IV, caudal re-piercings or ligatures with clearly visible lymph vessels. Submandibulectomy afterwards. Removal of the submandibular gland without complications. Some adjacent lymph nodes are also removed. The digastric muscle is severed. A tunnel is then created enorally, which is now sufficient with 2 QF. The radial lobe is then elevated. To do this, measure the defect (5 x 8 cm). A parallel procedure is now performed by elevating the radial lobe using <CLINICIAN_NAME> and <CLINICIAN_NAME> and dissecting the neck on the left side using <CLINICIAN_NAME> and <CLINICIAN_NAME>. Elevation of the radial lobe. Palpatory identification of the distal radial artery. Marking of the flap borders (6 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. For defect reconstruction on the forearm, full-thickness skin is harvested from the proximal forearm in the area of the S-shaped skin incision, thinned and sutured to the defect. Suturing of preparation swabs. Application of a wound dressing and a forearm splint. Completion of the graft lift without complications. Subsequent insertion of the flap: insertion of the flap into the defect. Insertion of the stem through the created tunnel. Subsequent successive suturing of the flap, which measures 6-7 x 5 cm. All relevant areas are successfully covered, including the floor of the mouth and the transition to the base of the tongue. Complete coverage of the bone. Subsequent vascular anastomoses: A branch of the facial vein and the middle thyroid vein are exposed and prepared for venous anastomosis. The arterial anastomosis is created using the radial artery and superior thyroid artery using 8.0 Ethilon single-button sutures. Here the clamps are still open, good arterial flow and good venous return. A total of 2 branches of a suture in the confluence and one from the cephalic region are then prepared for the anastomosis. The anastomosis of the smaller outlet with the V. thyroidea media is performed using a 2.5 mm coupler. Good venous return after opening the clamp. Positive smear phenomenon. The larger outlet from the pedicle is then anastomosed with the outlet from the facial vein using a 4.0 mm coupler. Here too, venous flow is good after opening the clamps, smear phenomenon positive. Subsequent clipping of all remaining open vessel ends. Careful irrigation and hemostasis. Wound closure in layers with insertion of a total of 2 flaps. Subsequent insertion of a gastric tube. A PEG was initially dispensed with. Then indication for tracheotomy due to significant swelling of the tongue. We waited until the end of the operation to carefully determine the indication for this procedure. There is now a clear swelling of the tongue, therefore tracheotomy by <CLINICIAN_NAME>. For this, incision of the skin just below the cricoid, sharp dissection in depth and ligation of the anterior jugular vein on the right side. Dissect the infralaryngeal musculature and reach the thyroid isthmus. This is undermined and bipolarized. Now reach the anterior wall of the trachea. Enter the trachea in the 2nd to 3rd intertracheal space. Epithelialization of the tracheostoma in the usual manner using 4 sutures and insertion of an 8-gauge tracheal cannula. Subsequent re-inspection of the flap enorally, which is well perfused. Completion of the procedure without complications. Postoperatively, the patient is ventilated and admitted to the intensive care unit. Please continue antibiotics, which were started intraoperatively with Unacid, for one week. Nutrition via gastric tube for approx. 7-10 days. Then build up the diet. Checking the vitality of the flap according to the scheme for 5 days. Overall T2 tumor at the alveolar ridge glossoalveolar junction and upper tonsil pole or lateral palatal arch area. cN0 situation in the neck area on both sides. Waiting for the final histology and then presentation at the interdisciplinary tumor conference.