After induction of anesthesia and intubation by the anesthesia colleagues, the patient is positioned. First, the tumor is inspected enorally. An exophytic tumor is seen in the area of the right tonsil with macroscopically clearly carcinomatous extensions towards the soft palate to the right parauvular region. Partly island-like tumor growth. The tumor extends towards the buccal and alveolar ridge, does not reach the maxilla. No deep infiltration of the soft tissues of the cheek, superficial growth also in the area of the alveolar ridge. The dorsal floor of the mouth is infiltrated via the glossotonsillar groove and the posterior floor of the mouth, also submucosal tumor growth towards the edge of the tongue. The right edge of the tongue is infiltrated over approximately half the length, approximately Ľ deep infiltration. Tumor growth to just before the posterior palatal arch. The posterior pharyngeal wall is free, as is the caudal pharyngeal side wall towards the entrance to the piriform sinus. Overall, the extent is clearly cT3. PEG insertion is performed first. This is done with the gastroscope. Careful endoscopy into the stomach. With excellent diaphanoscopy, problem-free puncture of the stomach and insertion of the PEG tube using the usual thread pull-through method. The patient is then prepared for definitive tumor resection. Injection of xylocaine with added adrenaline. First start with transoral resection. The tumor is completely marked and cut around with a safety margin of approx. 1 cm in the area of the oral cavity and 1.5 cm in the area of the tongue. All suspicious mucosal changes localized in the marginal area are removed. This results in a subtotal resection of the soft palate. Removal towards the upper jaw and soft cheek parts. Exposure of the pterygoid muscles. Clearly safe and free tissue conditions in depth. Incision of the alveolar mucosa. This is done sharply down to the bone. Detachment of the mucosa with removal of the periosteum. Resection of the posterior floor of the mouth. Resection of the right edge of the tongue. Resection up to the base of the tongue. Total approx. Ľ resection of the tongue. Part of the submandibular gland is removed transorally in the area of the posterior floor of the mouth to maintain a safety margin. The lingual nerve must also be resected during tumor resection. With macroscopic in sano resection of the tumor, marginal specimens are taken from the specimen that completely depict the primary tumor. These are completely resected as tumor-free in the frozen section diagnosis, therefore an overall R0 situation can be assumed here. The graft is now measured. The neck dissections are then carried out. The neck dissection of the right side and the tracheotomy were performed in parallel with the graft elevation from the left forearm. The neck dissection of the left side is performed first. To do this, make a curved skin incision on the front edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Exposure and transection of the platysma. Creation of a platysma flap. Exposure and preservation of the external jugular vein. Exposure of the sternocleidomastoid, omohyoid and digastric muscles. Exposure of the submandibular gland. Free dissection of the internal jugular vein with exposure and preservation of the facial vein. Dissection of the anterior neck preparation with careful preservation of the superior thyroid artery, the cervical artery and the hypoglossal nerve. Exposure of the accessorius nerve. Clearing of the accessorius triangle with careful protection of the nerves. Subsequent release of level V with careful protection of the cervical plexus branches. No caudal evidence of lymphatic leakage. Clinically no highly suspicious masses on the left side. After careful wound inspection, after wound irrigation, with dry wound conditions and insertion of a 10 Redon drainage, careful, two-layer wound closure. Subsequent repositioning for neck dissection on the opposite side. The procedure is basically the same here. Skin incision on the front edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Exposure and transection of the platysma. Creation of a platysma flap. Exposure of the sternocleidomastoid, omohyoid and digastric muscles. Clearing out the anterior neck preparation while carefully protecting the superior thyroid artery and the hypoglossal nerve. A facial vein is not developed here. Exposure and preservation of the external jugular vein. Complete dissection of the internal jugular vein. Clearing of the accessorius triangle with careful protection of the nerve. Evacuation of level V while protecting the cervical plexus branches. Level II revealed a lymph node measuring approx. 2 x 2 cm, round and therefore suspicious, otherwise subcapsular release of the submandibular gland. Resection of the remaining gland after, as described above, resection already by transoral resection. Careful release of level I b, here several lymph nodes measuring up to 1 ˝ cm. Now resection of the digastric muscle. Overall, a relatively wide shaft is now created enorally, approx. 3 transverse fingers wide. Careful wound irrigation and wound inspection. First turn to the plastic tracheotomy. To do this, make a skin incision at the level of the cricoid cartilage. Cut through the skin and subcutaneous tissue. Cut through the infrahyoid musculature. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. Dissection of the thyroid isthmus. Insertion between the 1st and 2nd tracheal ring. First creation of a broad-based pedicled Björk flap, this is relatively vulnerable, therefore a tracheal window is created. The trachea is then sutured in the usual manner using the back-stitch technique. Subsequently, intubation is first changed to a Woodbridge tube and later to a size 8 low cuff cannula. The radialis graft is then lifted from the left forearm. After the graft has already been measured enorally with a special soft palate and tongue edge configuration, a graft measuring up to 10 x 10 cm is marked. Positioning over the radial artery while protecting the retinaculum. Application of the tourniquet. Radial incision of the graft, taking the cephalic vein with it. Exposure of the brachioradialis muscle. Exposure of the superficial radial nerve ramus and preservation of the complete nerve in its course. Ulnar visualization of the flexor carpi ulnaris muscle. Identification of the distal vascular pedicle. Removal of the vascular pedicle after ligation. Strictly subfascial release with clipping of distal pedicle branches. Proximal dissection. Exposure of the ulnar artery. Exposure of the radial vein and artery. Exposure of the common interosseous artery. It is now apparent that the cephalic vein does not have a pronounced connection to the deep venous system, therefore several strong accompanying veins are elevated in relation to the graft. A total of 4 graft veins were elevated. After reopening the tourniquet, regular hand perfusion and excellent graft perfusion. Careful hemostasis of the graft and forearm. Subsequent removal of the vital graft after ligation of the feeding and draining vessels. The graft is then carefully implanted transorally. Overall good fit and intact conditions on all sides. Overall, somewhat laborious insertion conditions due to the size of the defect. In conclusion, however, a good result. Transcervical pedicle positioning. Conditioning of the superior thyroid artery. There is also a superior thyroid vein and the strong external jugular vein. After conditioning the flap vessels, perform the arterial anastomosis with Ethilon 8-0. Subsequently, create tight relationships. Select 2 strong, returning venous vessels. Anastomosis of a vein to the stump of the superior thyroid vein. Also anastomosis to the external jugular vein. Subsequent regular graft perfusion. Regular flow from the vessels with a positive smear test, so that a 10 Redon drain is inserted on the right cervical side if the graft perfusion is regular. Subsequent careful, two-layer wound closure. Now to the treatment of the left forearm. First, careful, two-layer wound closure after final wound inspection. Then insertion of the full-thickness skin graft harvested from the right groin. Careful trimming of the full-thickness skin. Final good fit. Subsequent application of a hydrogel and Mepilex dressing and application of the stretcher splint functional position. Now for full-thickness skin harvesting from the right groin. Trimming of a piece of full-thickness skin measuring approx. 14 x 10 cm. Strict cutaneous lifting. Final thinning of the graft. Subsequent extensive subcutaneous mobilization down to the abdominal fascia and the fascia lata. Careful hemostasis. Insertion of a 10-gauge Redon drain and careful, two-layer wound closure under very low tension conditions. Final inspection and completion of the procedure with a vital graft, without any indication of complications. The patient received intraoperative intravenous antibiotics with Unacid 3 g. Conclusion: Intraoperative R0-resected cT3 cN1 G2 oropharyngeal carcinoma on the right. Defect reconstruction using a microvascular anastomosed radialis graft. Postoperatively, please carry out an X-ray gruel swallow on the 8th to 9th postoperative day, after which a diet can be set up depending on swallowing function.