After appropriate preparation, first insertion of the PEG tube through <CLINICIAN_NAME> and <CLINICIAN_NAME> in the usual way. Subsequently, transition to transoral tumor resection. After adjusting the oropharynx with the tonsil retractor, a somewhat uneven mucosa can be seen in the area of the left tonsil. An exophytic or easily palpable tumor is not visible. If a caudal view of the lateral pharyngeal wall is possible with the retractor, a caudal tissue sample is taken to determine the extent of the carcinoma, which is not clearly visible. This sample proves positive in the frozen section histological diagnosis. Then start with monopolar tumor resection on the left side. The entire tonsil lobe is resected successively, starting at the parauvular left upper tonsil pole and removing the left anterior palatine arch and the adjacent posterior palatine arch with transition to the medial posterior hypopharyngeal wall. The entire musculature up to the soft tissues of the neck and the adjacent vessels is successively resected caudally. About 3/4 of the tumor is developed transorally downwards as far as possible. Subsequently, marginal sections are removed from the posterior wall of the hypopharynx, from the upper tonsil pole and from the lateral margin. Isolated tumor cell nests can still be found caudally in the area of the lateral margin, the remaining resected sections are tumor-free. Further excision will then be performed transcervically after completion of the neck dissection. Transition to neck dissection on the left side. A large fixed metastasis can already be palpated at the junction of regions II and III. After skin incision, dissection of the skin platysma flap laterally. The platysma is incised over the metastasis so that the skin can finally be moved laterally. Locate the vascular nerve sheath under the omohyoid muscle caudally. Trace the omohyoid muscle ventrally upwards. Then expose the anterior belly of the digastric muscle. Also expose the posterior belly of the digastric muscle. It can now be seen that the entire tumor block has even reached the caudal submandibular gland. Therefore, this is first removed by dissecting the facial vein and the facial artery while identifying and protecting the lingual nerve. In this way, the tumor block can be successively developed laterally starting at the submandibular gland while exposing and sparing the hypoglossal nerve. The external carotid artery, the carotid bifurcation and the common carotid artery are then exposed and released. The internal jugular vein is completely infiltrated, as are the sternocleidomastoid muscle and the accessorius nerve. Therefore, the internal jugular vein is deposited under the posterior belly of the digastric muscle after it has been found at the base of the skull. The internal jugular vein is also removed caudally in the area at the level of the clavicle. Dissection of the large tumor block and removal of the insertion of the sternocleidomastoid muscle at the tip of the mastoid. It is now apparent that the entire neck is full of hard nodular metastases down to the depth of the brachial plexus. The resection is therefore carried out as extensively as necessary and possible. The entire tumor block is successively resected radically, resecting all branches of the cervical plexus. Follow the tumor masses caudally, exposing and skeletonizing the phrenic nerve. The last metastasis is dissected free from the subclavian vein under traction. This leaves only the common carotid artery, the vagus nerve and the hypoglossal nerve on the left neck. Then widening of the opening in the neck and disluxation of the partially resected tumor. Then complete the tumor resection with parts of the base of the tongue and the remaining lateral to ................................. margin. This shows that the tumor has in principle grown through the lateral pharyngeal wall per continuitatem to the external carotid artery and can be detached from this in a healthy layer. After resection of an extensive section of the base of the tongue, as it is also affected by frozen section histology, all marginal sections of the base of the tongue as well as the remaining caudal and lateral hypopharyngeal wall are then tumor-free. Subsequent transition to elevation of the radial lobe graft by <CLINICIAN_NAME> and <CLINICIAN_NAME>. Palpatory identification of the distal radial artery. Marking of the flap borders (13 cm x 5.5 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. Now transition to neck dissection on the right side. Here, regions I-V are also selectively removed while preserving all lymphatic structures. Here too, a large lymph node metastasis is found in region II. The facial artery is then dissected beyond the lower jaw so that it can later be used for anastomosis. The V. facialis is also dissected as far beyond the mandible as possible while sparing the ramus marginalis mandibulae and cut caudally. After removal of the radialis graft, it is first sutured transcervically in the area of the base of the tongue and the caudal lateral hypopharyngeal wall at the level of the epiglottis and the vallecula. The remaining sutures are then performed transorally. After creating a transition to the opposite side, the flap pedicle is then transferred to the opposite side at the level of the hyoid. Here the arterial anastomosis of the radial artery to the facial artery is performed. The venous outflow is connected to the facial vein in an end-to-side manner via a vein in the flap. The 2nd humeral vein has a corresponding length so that it can be connected to the internal jugular vein on the right side in an end-to-side manner. A Redon suction drain and a drainage flap are then placed on the right side. Multi-layer wound closure. Completion of the mucocutaneous anastomosis of the tracheostoma. Re-intubation of the patient. End of the operation, transfer of the patient to anesthesia. Conclusion: Resection of a tonsillar carcinoma on the left side cT3 with radical neck dissection on the left and selective neck dissection region I-V on the right side. Reconstruction with a microvascularly anastomosed radial flap from the left forearm, which is inserted into the orohypopharyngeal defect on the left side and whose stalk is anastomosed to the right vascular nerve sheath. Due to the extensive tumor findings, adjuvant radiochemotherapy is strongly recommended.