First inspection of the primary tumor region after transnasal intubation and preparation by the anesthesia colleagues. Positioning of the patient. The ulcerated tumor described above is seen in the area of the underside of the tongue and the anterior floor of the mouth on the right side with a largely endophytic tumor component and complete fixation of the underside of the tongue on the right side corresponding to the preoperative clinic. No infiltration of the alveolar ridge. No infiltration of the left-sided floor of the mouth. The tumor is now cut around with a safety margin of a good 1 cm in the area of the anterior alveolar ridge. Here, the mucosa is pushed away from the bone, otherwise wide in sano resection in the area of the tongue, growth towards the outer muscles of the floor of the mouth, but these are not infiltrated. Exposure of the muscles of the floor of the mouth, no direct contact with the metastasis in level I on the right side. Macroscopic and palpatory in sano resection of the tumor, which is thread-marked for frozen section diagnostics and is resected in sano on the specimen. Scarce area basally towards the tip of the tongue with otherwise clearly in sano resection. For this reason, a resection is performed here to extend the safety margin, which is then used for definitive histology so that a safe in sano resection is finally available. Measurement of the defect. Turn first to the neck dissection and tracheotomy. Start with the right side. Submandibular incision. Cut through the skin and subcutaneous tissue. Separation and dissection of the platysma. Exposure of the sternocleidomastoid muscle and the omohyoid muscle. Release of the submandibular gland and exposure of the digastric muscle. This reveals a moderately displaceable, high-suspecting mass located in front of the submandibular gland, which lies against the mandible but still shows some displacement here. Exposure and dissection of the facial vein, which drains into the anterior jugular vein and the internal jugular vein. Excision of the submandibular gland, including level Ib, here some small but coarse and therefore conspicuous nodules. For resection of the metastasis, incision on the mandible on the periosteum. Push off the periosteum. However, the metastasis can be detached here. Deposition of the anterior venter of the digastric muscle if there is clear infiltration. Also circumscribed infiltration of the anterior floor of the mouth. Therefore clear perinodal spread here. En bloc entrainment, here from level Ia. Hypoglossal nerve, lingual nerve, lingual artery and facial artery can be preserved. Now free preparation of the internal jugular vein after exposure of the accessorius nerve. Dissection of the accessorius triangle and dissection of level V while carefully preserving the cervical plexus branches and exposing the common carotid artery and vagus nerve. Dissection of the internal jugular vein reveals a highly visible mass on the common carotid artery extending anteriorly into the jugulofacial angle. Careful dissection of the vein. There is a circumscribed infiltration of the mouth of the facial vein. This is therefore removed. The vessel to the anterior jugular vein is also removed. Complete and expose the internal jugular vein while maintaining cranial continuity and completing the neck dissection. The tunnel is created enorally. Create a tunnel measuring approx. 3 QF for stem positioning. Approach the neck dissection on the left side. Here also submandibular incision, cutting through skin and subcutaneous tissue, exposing and cutting through the platysma. Dissection of the platysma. Exposure of the sternocleidomastoid muscle and preservation of the external jugular vein and on the opposite side. Exposure of the omohyoid muscle. Release of the submandibular gland, taking the capsule with it. Exposure of the digastric muscle. Free preparation and preservation of the facial vein. Exposure of the accessorius nerve. Dissection of the internal jugular vein. Removal of the anterior neck preparation with careful exposure and protection of the cervical artery of the superior thyroid and the hypoglossal nerve and preservation of the facial nerve draining into the internal jugular vein. Exposure of the accessorius nerve. Complete according to level V, exploration of the sonographically described mass in level Vb. An oval, but rough and therefore suspicious mass measuring approx. 1 cm is actually found here. This is extirpated and level Vb is completed. Careful treatment of some leaking lymphatic fluid. Finally, absolutely dry conditions. Even after multiple inspections, the wound is finally irrigated, followed by insertion of a 10-gauge Redon drain and careful two-layer wound closure. The tracheotomy is then performed in the case of post-thyroidectomy. Horizontal incision below the cricoid cartilage. Cut through skin and subcutaneous tissue. Exposure and transection of the infrahyoid musculature. Exposure of the cricoid cartilage and the anterior surface of the trachea. Insertion between the 2nd and 3rd tracheal ring, forming a horizontal visor tracheotomy. Subsequent suturing of the mucocutaneous anastomosis, later problem-free reintubation on a low cuff cannula, which is suture-fixed. The defect is then measured. After tumor resection, this resulted in resection of the anterior third or anterior half of the right-sided tongue and resection of the anterior floor of the mouth. Due to the slender proportions, the decision was made to elevate and cover the defect with an anterolateral transfemoral graft. After doppler sonographic identification of the main perforator and marking of the anatomical landmarks, doppler sonographic identification of 2 secondary perforators, marking of the graft measuring a total of 6 x 8 cm with a special mouth floor configuration. Subsequent medial incision, cutting of skin and subcutaneous tissue. Exposure and securing of the rectus femoris muscle. Subcutaneous release while protecting the vascularized intermuscular septum. Performing a release incision after identifying the pedicle vessels. An oblique branch running steeply caudally and a further upper oblique branch can be seen. Identification of the main perforator with musculocutaneous course. Dissection of the main perforator. Initially, it can be seen that one of the secondary perforators extends from the main perforator; later, during dissection, the second secondary perforator can also be seen extending from the main perforator. After tracing the perforator, it can be seen to extend from the oblique upper vessel, leaving a small muscle cuff at the outlet of the perforator. Complete cutting of the graft after preparation of the vascular pedicle. Conditioning of the pedicle vessels and removal of the vital graft. Careful hemostasis in the area of the leg. Subsequent insertion of a 10-gauge Redon drain and careful two-layer wound closure with resection of excess skin. The graft is then incorporated transorally. This succeeds well and with sufficient volume filling in the area of the tip of the tongue and the missing lateral tongue. Positioning of the pedicle vessels, conditioning of the superior thyroid artery. Performing the arterial anastomosis with 8.0 Ethilon. Subsequent conditioning of the graft vein. Performing a venous anastomosis with the Coupler system on the superior thyroid vein in the correct pedicle position and graft perfusion. Subsequently, regular graft perfusion and positive spreading phenomenon and regular pedicle pulsation, so that subsequent careful wound closure on the right cervical side, subsequent termination of the procedure without any indication of complications. Note: Due to the patient's documented refusal of a PEG tube, a nasogastric feeding tube was inserted. The patient received intraoperative intravenous antibiotics with clindamycin, which should be continued for 24 hours postoperatively. Conclusion: Intraoperative R0 resected cT2 oral floor carcinoma on the right side with a strikingly aggressive and discontinuous metastatic pattern. Intraoperative cN2c neck status possible, therefore prompt adjuvant therapy should be initiated here. If the graft heals properly, swallowing diagnostics can be started from the 7th to 8th postoperative day. The insertion of a PEG tube during the interval appears to be necessary.