Induction of anesthesia by anesthesia colleagues, intubation by anesthesia colleagues. Sterile washing and draping. Insertion of a McIvor oral spatula and inspection of the tumor region. The tumor moves from the tonsil lobe to the soft palate, from there to the base of the uvula, to the anterior and posterior palatal arch, then to the posterior pharyngeal wall caudally to the right-sided vallecula and the lateral pharyngeal wall. Start with transoral tumor resection in the area of the soft palate. Successive resection of the tumor with a safety margin of 1 cm. Dissection down to the base of the tongue. The tumor also infiltrates the base of the tongue. Then change to the transcervical region. Skin incision in the area of the anterior border of the sternocleidomastoid. Exposure of the lower part of the sternocleidomastoid muscle. Exposure of the internal jugular vein in the lower part. Exposure of the omohyoid muscle. Then transection of the sternocleidomastoid muscle, because the N3 neck metastasis infiltrates the upper part of the muscle and also the vein. Then removal of the internal jugular vein. Dissection of the tumor from the internal carotid artery. The external carotid artery must also be removed due to tumor infiltration. In addition, superficial plexus branches and the accessorius nerve must also be removed, as well as the hypoglossal nerve and the submandibular gland. Level I also contains large, conspicuous nodes. Level I is therefore also removed. The tendon of the omohyoid muscle, which is also infiltrated, is severed. The caudal part of the parotid gland is also infiltrated and the oral branch must also be resected. The tumor is in direct contact with the N3 neck metastasis, but is not completely connected to it, so it is possible to remove the metastasis separately from the tumor and also the remaining neck tissue. The tumor is then pulled outwards from the transcervical area and resected. The result is a fairly large, three-dimensional defect from the vallecula up to the soft palate. The defect is then measured and the graft designed. The graft is designed so that it is 17 cm long and has an angled section for tongue reconstruction, which is also approx. 8 to 9 cm in size. This graft is then lifted by <CLINICIAN_NAME> on the arm. Mark the graft for this purpose. Skin incision. Visualization of the vascular situation in the crook of the elbow and the vascular pedicle. Exposure of the superficial ramus of the radial nerve, which is divided into 2 branches. One branch is severed by <CLINICIAN_NAME> due to the size of the graft. However, the main branch remains intact. Now change the operators from <CLINICIAN_NAME> to <CLINICIAN_NAME> and complete the graft elevation. To do this, lift the graft from the tendon bed. Exposure of the brachioradialis muscle and preparation of the pedicle in the usual manner. Then further dissection of the vascular situation in the crook of the elbow and removal of the graft while preserving 3 venous vessels. Marking of the radial artery. Now conditioning of the vessels in the neck area. The stump of the internal jugular vein is already thrombosed, as is the stump of the external jugular vein. This is no longer an option for the transplant. An accompanying vein in the area of the omohyoid is prepared. The stump of the external artery is also already occluded and is no longer suitable as a connecting vessel. The superior thyroid artery is therefore prepared and conditioned. Now fitting the graft into the defect and suturing the graft, mostly transcervically. This is extremely difficult because the graft is very large and very bulky and also because of the considerable swelling in the palate, uvula and tongue. In the end, the graft was able to fit completely. Now the vessels are anastomosed, first the arterial and then the venous vessels. Only one venous vessel can be connected, as the other two do not show any blood return; they are clipped. A flap is then inserted and the wound is closed in two layers. Parallel to the graft elevation, the neck is dissected on the left side, initially through <CLINICIAN_NAME> and <CLINICIAN_NAME>. Exposure of the sternocleidomastoid muscle. Representation of the omohyoid muscle. Exposure of the cervical vascular sheath. Free preparation of the internal jugular vein. Exposure of the submandibular gland. Exposure of the omohyoid muscle. Clearing of the medial neck block with preservation of the facial vein and artery. Exposure of level IIa with preservation of the accessorius nerve. Then transfer of <CLINICIAN_NAME> and removal of neck levels II b to V a while preserving the plexus branches. Insertion of a Redon drainage, two-layer wound closure. Then perform the tracheotomy through <CLINICIAN_NAME> and <CLINICIAN_NAME>. Make a skin incision below the cricoid cartilage. Dissection down to the musculature. Splitting of the musculature in the linea alba. Exposure of the thyroid isthmus. Dissection of the thyroid isthmus. Exposure of the anterior wall of the trachea. Entering the trachea between the 2nd and 3rd tracheal cartilage. Creation of a visor tracheotomy. Creation of a mucocutaneous anastomosis and reintubation on an 8 mm tube. A flap is inserted in the area of the right side of the neck and a two-layer wound closure is performed. The patient goes to IOI intubated and ventilated due to heart and lung problems. Please perform an X-ray gruel swallow on the 10th postoperative day. Continue antibiotics for at least 24 hours.