First, pharyngoscopy and inspection of the tumor findings, which extend submucosally far into the soft palate with a center in the area of the tonsil lobe. Submucosally, the tumor reaches the uvula on palpation and thus the median line of the soft palate. However, it can be differentiated from the hard palate. Furthermore, the tumor extends over the lateral pharyngeal wall, the angle of the jaw, straight onto the base of the tongue and ends caudally just above the lateral wall of the piriform recess. The tumor is now cut around from the enoral side with the monopolar and the scissor blade with an appropriate safety distance of approx. 1 cm. After in toto resection, the specimen is thread-marked and sent for histopathological frozen section evaluation. This reveals an R1 situation caudally in the area of the glossotonsillar groove, so that a resection and a further final marginal sample are sent for frozen section diagnosis. This is now tumor-free. The neck is first dissected, initially on the right side: a skin incision is made along the anterior edge of the sternocleidomastoid. Dissection of the platysma and creation of a cranial platysmal flap. The external jugular vein and the auricular nerve are spared. Dissection of the vascular nerve sheath while sparing the vascular nerve structures. Dissection along the omohyoid muscle to the hyoid bone and along the digastric muscle to the laterobase. All vascular nerve structures can be preserved on the right side and levels II, III, IV and Va are removed. A lateral pharyngotomy is then performed to insert the pedicle, taking the posterior digastric venter muscle with it to prevent narrowing of the pedicle. The facial vein and the lingual vein also cross the pedicle passage so that they are ligated and cut. A lumen 2 to 3 transverse fingers in size is now created to allow the stem to pass through easily and without pressure. This is followed by the neck dissection on the left side: for this purpose, a skin incision is also made along the front edge of the sternocleidomastoid muscle in the case of two previous left cervical operations. Here, the vascular nerve sheath is dissected and the vascular nerve structures are preserved in difficult, scarred conditions. Dissection along the omohyoid muscle up to the hyoid bone and along the digastric muscle up to the laterobasis. Completion and elevation of the level II and III neck block without conspicuous lymph node pathology macroscopically. Furthermore, clearing of level Va. Macroscopically, there are no abnormal lymph nodes on the left side. However, the assessment is limited due to the scarring situation in the case of previous surgery. Parallel to the neck dissection, elevation of the radialis graft from the left forearm in tourniquet (300 mm/Hg). After measuring the graft to be lifted and marking the intended structure of the defect coverage, the lift is performed in the typical manner using a skin monitor. Skin flaps are created and subfascial preparation is made on the brachioradialis muscle. The cephalic vein is included in the elevation in order to integrate the superficial venous system into the venous drainage. Dissection distally and after using the Hayden maneuver, identification of the radial superficial ramus nerve. Protection of the nerve. Locate the vascular pedicle, cut it and further dissect the ulna. Here, too, subfascial dissection with protection of a peritendineum. Lifting now from distal to proximal into the crook of the elbow. There is no transition from the deep to the superficial venous system in the sense of a venous bridge, so that a deep vein is provided in the antecubital fossa as a connecting vein after the venae comitantes have been brought together. The cephalic vein, on the other hand, is ligated accordingly. Separation of the radial artery above the interosseous artery. The ulnar artery is clearly identified beforehand. After initial vascularization due to cold in the area of the flap, with good blood supply to the forearm and hand, after opening the tourniquet, the blood supply to the graft is regular after appropriate warming. For this reason, the graft is not lifted for half an hour to allow it to recover. This takes place completely. After careful hemostasis of minor bleeding in the area of the graft, the graft is now set down accordingly and inserted from the outside to the inside into the enoral defect for reconstruction of the soft palate and the lateral pharyngeal wall. Parts of the tongue body are sutured primarily. Incorporation leads to a successful reconstruction of the structures to be treated, followed by microvascular anastomoses. For this purpose, the superior thyroid artery is anastomosed end-to-end with the flap artery using 8/0 nylon sutures. The vein is anastomized end-to-end using a 2.5 mm vascular coupler. If the vascular flow is regular and the flap is well perfused, a fat seal is inserted into the pedicle curvature in addition to the skin monitor for better pedicle positioning. Subcutaneous sutures and skin suture on the right cervical side with insertion of a flap. On the left cervical side, the skin suture is performed in the classic sense in the form of a subcutaneous and single-button skin suture and insertion of a Redon drain. Meanwhile, the forearm is partially closed primarily and covered in the area of the lifting defect with full-thickness skin from the right groin, which was previously removed, and covered with a vacuum dressing, which should remain in place for 7 days. Application of a Cramer splint. Repositioning of the hand and forearm. Finally, creation of a tracheostoma. For this, a typical jugular skin incision is made and, after subcutaneous preparation and lateral displacement of the infrahyoid muscles, the thyroid isthmus is cut. Dissection of the anterior surface of the trachea. Creation of a caudally pedicled stoma and suturing of the stoma edge to the skin. Transfer intubation to a blockable Lanz cannula and suture the cannula. The cannula must remain in place for 5 days and any bandages and pressure in the neck area should also be avoided. The vessels are monitored by vascular Doppler examination and inspection of the skin monitor every hour for the first 72 hours and every 4 hours for a further 48 hours. If problems arise, the surgeon can be informed by telephone at any time. The patient is intubated and ventilated overnight for monitoring in the intensive care unit.  