Induction of anesthesia and intubation by anesthesia colleagues. Performing flexible oesophagoscopy and gastroscopy and inserting a PEG using the thread pull-through method. This can be done without any problems with good diaphanoscopy. Insertion of a covered retractor and looping of the tongue. Inspection of the tumor. A tumor at least 4 cm in size can be seen on the middle third of the tongue margin. The tumor extends to the floor of the mouth, but does not involve the anterior floor of the mouth or the base of the tongue. Incision of the mucosa using a monopolar needle with a safety margin of 1 to 1.5 cm. Removal of the tumor using scissors, bipolar forceps and palpation. The tumor penetrates deep down to the midline of the tongue. The tumor can be removed in its entirety. The tumor preparation is thread-marked in its entirety for frozen section. This is clearly an R0 situation. Due to the large resulting defect, the decision was made to cover the defect with a radialis graft to improve function. Therefore neck dissection on the left side. Neck dissection on the right side is not performed due to the lack of infiltration of the base of the tongue and anterior floor of the mouth and a cN0 neck status on the right side. Transverse neck incision. Exposure of the platysma. Formation of a cranial and caudal platysma flap. Exposure of the sternocleidomastoid muscle, the omohyoid muscle and the posterior belly of the digaster and the submandibular gland. Release of the neck preparation Leves II a/b as well as III, IV and V, while sparing the plexus branches. Level V is integrated into the neck preparation, as some lymph nodes could be found here. Release of the submandibular gland and removal of fatty tissue in level I b. Dissection of the digastric muscle and formation of an enoral tunnel. Lifting the radialis graft. Drawing of the radial artery. Marking of the graft. Cutting around the graft. Incision of the skin up to the crook of the elbow. Exposure of the brachioradialis muscle. Exposure of the venous star in the antecubital fossa with basilic vein, cephalic vein and the confluence between the superficial and deep venous system. Exposure of the superficial ramus, the radial nerve with its splitting. This can be completely preserved. Exposure of the radial artery. Ligating and separating the radial artery. Release of the skin flap by exposing the tendons of the forearm. Dissection of the pedicle up to the crook of the elbow. Removal of the confluence. Marking of vein and artery. Closure of the forearm using split skin from the right thigh. Suturing of the graft. Pulling the graft through enorally. Suturing of the graft both in the tongue area and in the floor of the mouth. Repositioning of the patient to perform the vascular anastomosis. Conditioning of the superior thyroid artery and the facial vein. First the arterial anastomosis is performed, then the venous anastomosis using a size 4 coupler. Insertion of a Redon drain and two-layer wound closure. Completion of the operation without complications. There is good blood flow to the graft at the end of the operation. The patient is ventilated and admitted to the intensive care unit.  