First inspection of the primary tumor region after intubation by the anesthesia colleagues. Positioning of the patient. Entry with the tonsillar retractor. Inspection and palpation. The exophytic lesion can be seen in the area of the right tonsil lobe. On palpation, the lesion is submucosal and extending into the soft palate, with infiltration of the posterior palatal arch. Laterally, the mass is still displaceable. In this case, the tonsil capsule is barely exceeded. The tumor is now resected in the sense of a radical tonsillectomy. In the area of the submucosal part of the soft palate, the resection must be carried out as far as the parauvular area and a clear resection of the soft palate. The tumor itself is relatively well encapsulated, but takes up the entire tonsil lobe. Inclusion of the posterior palatal arch muscularly and in the area of the mucosal level. A muscle cuff is also left laterally and the lower tonsil pole is included. In this case, the tumor does not significantly protrude. On the specimen, the specimen is now resected in sano, but with encapsulation basally probably histologically barely in sano resection. Therefore, the tumor is completely covered basally and in the mucosal area by taking marginal samples. These are diagnosed as completely free of tumor and dysplasia in the frozen section diagnostics, so that a reliable R0 situation is present here. Due to the resection down to the soft tissues of the neck and the large area of exposed neck fatty tissue as well as the resection of almost half of the soft palate and resection of the posterior palatal arch, a radialis graft is indicated to cover the defect for the best possible functionality. The PEG tube is initially inserted if the neck status is positive. Insertion with the gastroscope under laryngoscopic control. Easy pre-transmission into the stomach. If the mucosal conditions here are unremarkable and the diaphanoscopy is good, the stomach is punctured without any problems and the PEG tube is then inserted using the usual thread pull-through method. Neck dissection of the left side is then performed first. Submandibular incision. Separation of skin and subcutaneous tissue. Dissection of the platysma for complete exposure of the neck area. Perform a functional neck dissection level II to IV, exposing and protecting the submandibular gland, sternocleidomastoid muscle, omohyoid muscle, digastric muscle, internal jugular vein, facial vein, cervical artery, superior thyroid artery, hypoglossal nerve and accessory nerve. Followed by careful wound inspection, wound irrigation and, if the wound is dry, insertion of a 10-gauge Redon drain and careful, two-layer wound closure. Turning to the opposite side. Here in level II, a mass measuring approx. 4 cm. First cut through the skin and subcutaneous tissue. Dissection of the platysma, which is not infiltrated. Exposure of the sternocleidomastoid muscle, omohyoid muscle, submandibular gland and digastric muscle. The mass is relatively smoothly encapsulated, no infiltration of the sternocleidomastoid muscle. Free preparation of the anterior neck specimen, with careful protection of the hypoglossal nerve, superior thyroid artery and facial vein. Dissection of the internal jugular vein. The mass lies on the vein, compresses it, but does not infiltrate it. Similarly, exposure and preservation of the accessorius nerve, which is also only in contact with the mass. There is also no infiltration of the digastric muscle. Complete the neck in level V, carefully preserving the cervical plexus branches. Finally, resection of the digastric muscle and performance of a pharyngotomy and creation of a tunnel measuring approx. 3 transverse fingers enorally for compression-free style positioning. The radialis graft is now removed from the left forearm in a bloodless state. Draw a graft measuring 10 x 5 cm in total with a special soft palate configuration. Trimming of the graft. Radial dissection with the cephalic vein located far dorsally, leaving it intact. Exposure and preservation of the ramus superficialis nervi radialis. Exposure of the brachioradialis muscle. Distal transection of the radial artery. Ulnar preparation. Strictly subfascial preparation and release of the specimen. Isolation on the vascular pedicle. Exposure and preservation of the common interosseous artery. Exposure and dissection of a venous confluence and removal of the excellent vital graft, after reopening of the tourniquet and regular hand perfusion. Subsequent careful wound inspection and hemostasis in the forearm area. Careful wound closure and incorporation of the full-thickness skin graft harvested from the right groin. Subsequent application of the vacuum pump. Application of the Kramer splint in the functional position and repositioning of the arm at the end of the procedure. For full-thickness skin harvesting from the right groin. Incision of a spindle-shaped area of skin measuring 12 x 5 cm in total. Strictly cutaneous lifting. Followed by subcutaneous mobilization. Hemostasis and, if the wound is dry, insertion of a 10-gauge Redon drain and careful, multi-layer wound closure under moderate tension. The radialis graft is then incorporated. Despite the advanced swelling of the tongue, this was sufficient and regular. Good soft palate reconstruction and intact conditions on all sides. Stalk positioning and conditioning of the superior thyroid artery and performance of the arterial anastomosis with 8-0 Ethilon. Subsequently, immediate regular venous return and good graft perfusion. Conditioning of the facial vein and insertion of the venous anastomosis with the size 3.5 coupler, followed by careful irrigation of the wound if the graft circulation is normal and, if the wound is dry, insertion of a 10 Redon drain and careful, two-layer wound closure. Subsequently, due to the advanced swelling of the tongue and the extent of the graft, a protective tracheostomy is performed. This involves a circumscribed skin incision below the cricoid cartilage. Cut through skin and subcutaneous tissue. Exposure and transection of the infrahyoid musculature. Dissection of the thyroid isthmus. In the case of protective tracheotomy, only punctual epithelialization. Subsequent problem-free reintubation to a size 8 low-cuff cannula, suture-fixed. The procedure was then completed without complications. Conclusion: Intraoperatively R0 resected cT2 cN2a tonsillar carcinoma on the right. Postoperative meticulous flap monitoring by enoral inspection. If the graft has healed properly, the patient can be gradually built up and decannulated from the 7th to 8th postoperative day. After receiving the definitive histology, presentation at our interdisciplinary tumor conference to determine the adjuvant therapy.