Start with insertion of the PEG tube: Perform flexible gastroscopy for this purpose. Enter with the gastroscope under laryngoscopic control. Problem-free pre-scanning into the stomach. If the diaphansocopy is very good, puncture the stomach without any problems and pull the PEG tube through using the usual suture pull-through method. Inconspicuous esophagus on reflection. Then turn to enoral tumor resection: inspection. The entire left tonsil is found to be tumorously bulging submucosally, the tumor extends close to the uvula, infiltrates the soft palate and extends up to about 1/3 of the posterior pharyngeal wall. The tumor extends towards the buccal and alveolar ridge as well as to the pharyngeal side wall at the level of the hypopharyngeal entrance, transition to the glossotonsillar groove. Contrary to the CT image, the base of the tongue itself is not infiltrated. Now cut around the tumor with the monopolar with a safety margin of at least 1 cm in case of growth into the left uvula base. Subtotal resection of the soft palate. Dissection shows that the tumor has a kind of pseudocapsule and appears relatively well encapsulated. Further excision of the tumor with sufficient safety distance using the dissection technique. Resection close to the alveolar ridge in the posterior region of the molars. All-round removal of the tumor macroscopically in healthy tissue. The carotid artery can be palpated in depth, but no direct contact. In the area of the posterior pharyngeal wall, a good displacement layer is already visible above the deep cervical fascia. The tumor can be released in its entirety here. Resection of the right posterior pharyngeal wall via the midline. Resection circumscribed in the area of the glossotonsillar groove, as described above, no infiltration of the base of the tongue. The tumor specimen is thread-marked for final histology. Clearly representative marginal samples are now taken in the entire adjacent mucosal area as well as basally in the area of the upper tonsil pole and in the area of the pharyngeal musculature. Macroscopic resection is most likely here. In frozen section diagnostics, all marginal samples are found to be tumor-free. The result is a subtotal soft palate defect with a defect in the posterior pharyngeal wall extending beyond the midline and to the lateral pharyngeal wall in the area of the transition to the hypopharynx. In addition, circumscribed resection of the glossotonsillar groove and the posterior floor of the mouth. Resection of the right tonsil using the dissection technique, meticulous hemostasis. A defect measuring a maximum of 11 x 7 cm is now measured and an appropriately configured radialis graft is designed. From here, parallel preparation of the neck dissection and the radial distal graft. First for the neck dissection - start with the right side: make a submandibular curved incision. Cut through the skin and the subcutis. Exposure of the platysma. Dissection of the platysma. Creation of a platysmal flap. Exposure of the external jugular vein and the auricular nerve. Sparing of the structures. Exposure of the anterior border of the sternocleidomastoid muscle. Free preparation of the muscle and exposure of the omohyoid muscle. Freeing of the muscle up to the hyoid. Exposure of the submandibular gland. Complete the anterior direction of the hyoid. Expose the entire length of the digaster muscle. Now continue exposing the neck preparation anteriorly. Expose the cervical anus. Expose and preserve the facial vein, expose the hypoglossal nerve and the superior thyroid artery. Now dissect dorsally. Release the accessorius triangle while carefully preserving the nerve and complete level Va while carefully preserving the cervical plexus. Final inspection and, if the wound is dry, insertion of a 10 Redon drain and careful, two-layer wound closure. All the anatomical structures mentioned here were preserved. Now turning to the opposite side: Here, the same procedure was followed in principle. After creating a platysmal flap, expose the sternocleidomastoid muscle, omohyoid muscle, submandibular gland and digastric nerve. During dissection of the internal jugular vein, several tributaries to the internal jugular vein are visible here (as well as on the opposite side) in addition to the facial vein. These are all spared. In the area of the jugulo-facial angle, a lymph node of conspicuous size and shape is now visible on the left. Release the specimen anteriorly while also sparing and exposing the hypoglossal nerve, cervical artery and superior thyroid artery. Complete the neck dorsally while carefully protecting the accessorius nerve and the cervical plexus. Now remove the digastric muscle. Further dissection and performance of a pharyngotomy below the tonsil lobe. Creation of an approx. 3-finger wide access. Radialis graft: First identify the cephalic vein. Marking of the graft. A skin monitor is also lifted. Application of the tourniquet to 300 mmHg. Skin incision and preparation of a skin flap while carefully preserving the subcutaneous vascular tissue. Exposure of the cephalic vein. Strictly subfascial dissection and performance of the Hayden maneuver. Identification of the superficial ramus and radial nerve. Both branches can be exposed and preserved. Now expose the vascular pedicle. Blunt exposure of the radial artery with its accompanying veins. Ligation of the vascular pedicle. Now successive lifting of the graft under strictly subfascial preparation. Develop the graft cranially while carefully supplying the feeding vessels. A classic vein pattern with cubital outlet of the cephalic vein can be seen in the area of the antecubital fossa. In the area of the cubital fossa, the anatomy is also classic with a regular outlet of the interosseous artery and the ulnar artery. A broad vascular bridge of the deep venous area of the radial artery and the superficial outflow area can now also be seen. Now open the tourniquet. Minutious hemostasis. Regular or excellent flap perfusion with regular arm perfusion. Deposition of the graft after ligation of the remaining draining and supplying vessels. Then removal of full-thickness skin from the right groin. Skin incision for this. Strict cutaneous preparation. Careful hemostasis and, after skin mobilization, careful, multi-layered subcutaneous closure with moderate tension and skin suturing. Prior to this, insertion of a 10 Redon drain. Now inspection of the forearm. Final hemostasis and, if the wound is dry, careful two-layer wound closure and insertion of the full-thickness skin graft and final treatment with a vacuum sealing dressing and application of the Cramer splint. Now to the suturing of the graft. Start suturing the graft transorally. First suturing of the dorsal resection border, suturing of the palatal arch replacement in the area of the tonsil lobe, especially in the area of the transition to the glossotonsillar groove and the posterior floor of the mouth. Extremely difficult suturing conditions, also in the area of the pharyngeal side wall. Difficult suturing due to poor accessibility, but finally a tight and gap-free fit. The caudal end of the flap must be sutured in transcervically. Here, after exposing the pharyngotomy, relatively problem-free suturing. Here too, good adaptation with an overall adequate flap size. Now turn to the vascular anastomosis. The superior thyroid artery is further exposed, clamped and dissected free. Vascular anastomosis with 8.0 Ethilon. Slightly more difficult due to the position of the vessel, but overall without complications. After opening the clamp, good and tight vascular anastomosis with good flow and good venous return. Now select the venous vessel with the better return flow. Clip the 2nd vein. Measure a 2.5 mm coupler. Expose and carefully dissect the facial venous branch. Deposition after clipping and coupler anastomosis. In this case, the posterior part of the coupler cannot be placed correctly so that a sufficient anastomosis cannot be created. The coupler must therefore be removed. At the next attempt, coupler placement without complications, also with 2.5 mm density and sufficient anastomosis with good arterial and venous flow. Regular blood supply to the skin monitor, so that after flap application, the wound was carefully closed in two layers in dry wound conditions. A tracheotomy had already been performed previously due to the size of the defect, the size of the flap and the tongue swelling that occurred during the incision. For this purpose, the skin incision was made horizontally, sparingly below the cricoid cartilage. Dissection of the subcutaneous tissue. Exposure of the infrahyoid musculature. Splitting of the musculature. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea and insertion between the 2nd and 3rd tracheal ring. Creation of a Björk flap and performance of the mucocutaneous anastomosis. Finally, problem-free reintubation to an 8-gauge cannula with inner core and completion of the procedure, overall without any indication of complications. Conclusion: R0 resection of a cT3 cN1 tonsillar carcinoma on the left. The antibiotic treatment with Unacid 3 g started intraoperatively should be continued for at least 24 hours. The sutured cannula should be left in place until the 5th postoperative day. Leave the Cramer splint and Vac bandage in place for 7 days. A diet can be started from the 8th postoperative day if the flap is healing well. However, findings should be checked by the surgeon beforehand.