First induction of anesthesia and intubation transnasally by the anesthesia colleagues. Then, entry with the Kleinsasser tube and inspection of the tumor. The tumor starts at the lower edge of the left tonsil and extends over the entire oropharyngeal side wall on the left side to the left vallecula and epiglottis edge, then sterile washing and draping and insertion of a Mc Ivor mouth block and start with a transoral tumor resection with a safety margin of 1 cm to 1.5 cm. Then repositioning for neck dissection on the left side. Skin incision at the anterior margin of the sternocleidomastoid muscle, exposure of the sternocleidomastoid muscle, the omohyoid of the submandibular gland, the digaster and the accessorius nerve, exposure of the cervical vascular sheath and exposure of the internal jugular vein. It becomes clear that there is a metastasis in level II that cannot be separated from the internal jugular vein, so the neck dissection is temporarily stopped on the left side and the procedure is switched to the opposite side so that the internal jugular vein can be safely preserved there. Here also skin incision in the usual manner. Exposure of the sternocleidomastoid muscle, the omohyoid muscle, the digastric muscle, the accessorius nerve, release of the medial neck block while sparing the facial vein. Then release of the neck block in levels IIb, III and IV while sparing the plexus branches. The internal jugular vein can be completely preserved. Now switch back to the left side and complete the neck dissection on this side while ligating and repositioning the internal jugular vein so that the metastasis in level II can be safely removed. Release the neck blocks IIb, III, IV and Va while sparing the plexus branches. The facial vein, which in this patient originates very far caudally from the internal jugular vein, can be preserved. The superior thyroid artery can also be preserved. Then remove the submandibular gland while sparing the lingual nerve and the lingual artery. Dissection of the omohyoid muscle and creation of an enoral access. Further tumor resection from the transoral side. The tumor can be retrieved en bloc and is suture-marked for frozen section. There is still carcinoma in situ on the posterior pharyngeal wall towards the medial side. Here, another large resection is performed and a final margin sample is taken. The final marginal sample R0, finally all R0. Lifting of the radialis graft by <CLINICIAN_NAME>. The radialis graft is lifted 9 x 7 cm, from the left side. To do this, first mark the graft and the skin incision on the forearm up to the elbow. Then make a skin incision in the marked area, expose the venous plexus in the elbow area, then expose the brachioradialis muscle. Visualization of the medial antebrachial cutaneous nerve, then visualization of the superficial ramus, the radial nerve with its branches. Locate the radial artery, clamp the radial artery using a vascular clip for 10 minutes. The connected pulse oximeter shows a continuous 100 % oxygen saturation, so that the radial artery can finally be severed and stitched with an overlocking suture. The radialis graft is then lifted off the tendons while sparing the ulnar artery and the superficial ramus of the radial nerve. Dissect the pedicle cranially while clipping off the branches. A superficial and a deep vein are taken from the venous system with good confluence. Deposition of the radialis graft first in the venous limb, here it becomes apparent that only the deep vein conveys blood to the outside, the superficially prepared vessel does not convey blood and probably cannot be used for anastomosis. Now the arterial limb is removed and the radialis graft is fitted into the defect. This is very difficult as the defect is three-dimensional and sutures must be placed transcervically and the graft sutured in place. The rest is sutured in from the transoral side. This is again very difficult on the posterior pharyngeal wall in the cranial region, as the defect also extends very far towards the border of the nasopharynx due to the resection. Then preparation of the blood vessels. The superior thyroid artery is prepared as the artery and the facial vein as the vein. Now perform the arterial anastomosis in the usual manner with Ethilon 8-0 and then the venous anastomosis with a size 3.5 coupler. Insertion of a Redon drainage very far dorsally and two-layer wound closure on both sides. A Redon drain was also inserted on the right side. A tracheotomy was performed at the same time as the flap was lifted. Skin incision below the cricoid cartilage, separation of the fatty tissue, then exposure of the musculature and the linea alba, splitting of the musculature in the linea alba. Exposure of the thyroid isthmus. Dissection of the thyroid isthmus, visualization of the anterior wall of the trachea. Entering the trachea between the 2nd and 3rd tracheal cartilage. No Björk flap is created and later reintubation to a tracheal cannula 9.0 without any problems. The split skin is also removed from the right thigh at the same time as the graft is lifted; this is then sutured to the forearm in the usual way and a dorsal forearm splint is fitted. The patient is ventilated in the intensive care unit, given antibiotics for at least 24 hours and the flap is checked according to the usual schedule.