First pharyngoscopy and laryngoscopy: The exophytic tumor is seen, which is located at the posterior edge of the tongue, infiltrates the base of the tongue and extends via the glossoalveolar groove into the tonsillar lobe in the anterior region. This confirms the spread of the tumor and the indication for resection, with flap coverage if necessary. This is followed by transoral resection of the tumor, taking into account the macroscopically visible borders and also the palpatorily recognizable borders. Incision around the tumor with a safety margin of 1 to 1.5 cm on all sides. The posterior area of the tongue up to the middle, including the base of the tongue, the mucosa up to the tonsil lobe over the glossotonsillar groove, the anterior area of the palatal arch. The resection extends caudally to the entrance to the hypopharynx. The preparation is thread-marked and sent for frozen section examination. No evidence of tumor in the entire margin of the specimen, even basally, thus R0 resection. Due to the extent of the defect, flap coverage is indicated in any case. The lingual nerve had to be sharply dissected away from the tumor. The PEG is now placed: pre-splinting through the esophagus into the stomach. Here, after establishing spontaneous diaphanoscopy, insertion of a 15 mm abdominal wall tube without complications. Fixation to the abdominal wall in the typical manner. Subsequent repositioning for neck dissection: skin disinfection and injection of a total of 10 ml Ultracaine 1% with adrenaline into both sides of the neck. Sterile draping. Skin incision first on the left in the typical manner. Depiction of the sternocleidomastoid muscle. Depiction of the omohyoid muscle. A lymph node conglomerate can be seen cranially, which infiltrates the sternocleidomastoid muscle, which is therefore also resected cranially. The digastric muscle is also resected as it is also included in the conglomerate. Spatial mass or lymph node conglomerate also infiltrates the internal jugular vein in the cranial region and the accessorius nerve, both of which must be resected. The internal and external carotid arteries as well as the superior thyroid artery, facial artery and lingual artery can be visualized and preserved. The vagus nerve and hypoglossal nerve, which can be dissected away from the tumor conglomerate, can also be preserved. This results in the removal of level II to V with exposure of the branches of the cervical plexus. The submandibular gland is also removed. A wide tunnel is then created enorally to allow the pedicle to pass through. Neck dissection on the right side. Skin incision along the anterior border of the sternocleidomastoid muscle. Exposure and ligation of the external jugular vein. Exposure and sparing of the auricular nerve. Exposure of the digaster muscle and the cranial accessorius nerve as well as the caudal omohyoid muscle. Exposure of the capsule of the submandibular gland and the hypoglossal nerve. Subsequent exposure of the internal jugular vein from caudal to cranial and complete dissection of the cervical vascular sheath from the multiple suspected metastases in the right anterior neck preparation, particularly in levels II and III. Repeated hemostasis using bipolar coagulation. The multiple cervical metastases on the right side were completely removed while sparing the plexus branches, the accessorius nerve and the hypoglossal nerve. Dry conditions. A complete removal of levels I b, II, III, IV and V was performed, leaving the submandibular gland intact. Wound irrigation with hydrogen peroxide and Ringer's solution. Insertion of a 10-gauge Redon drain and two-layer wound closure. Now proceed to tracheotomy: skin incision a total of 5 cm horizontally below the cricoid cartilage and sharp cutting of the skin and subcutaneous tissue using a 15 mm scalpel. Further dissection in depth using pointed scissors. Jugularis anterior is identified, cut and ligated, no bleeding. Now locate the anterior neck muscles and cut through the linea alba. The musculature is pushed to the side. Further dissection in depth with identification of the thyroid gland and thyroid capsule. The isthmus is small, the gland is also relatively small. Bipolar coagulation of the isthmus and transection of the isthmus. Now identification of the 2nd and 3rd tracheal ring. Creation of a Björk flap, for which both thyroid lobes are bluntly pushed aside and the trachea is opened using pointed scissors. Targeted bipolar coagulation. Now 3 sutures are placed caudally using Ethibond and 3 sutures cranially to ensure sufficient epithelialization. Suturing is performed without any problems. Skin suture with 4-0 Ethilon, 8-gauge cannula is inserted without any problems. Change of cannula on the 5th postoperative day and suture removal between the 7th and 10th postoperative day. Then elevation of the radial flap from the left forearm: After measuring the defect, a flap, length 10 cm, width 6 ˝ cm, is recorded according to the three-dimensional configuration. Subsequently, first ulnar subfascial elevation of the flap. Then extension of the incision curved into the olecranon. Visualization of the surface vein system with connection to the flap pedicle. Subsequent radial subfascial elevation of the flap. Exposure of the lateral antebrachial cutaneous nerve and preservation of this as far as possible. Caudal exposure of the radial artery, which is first clamped. First expose the pedicle up to the elbow. Dissection of the pedicle also from the brachioradialis muscle distally. Then cut the radial artery and treat it using 4-0 prolene stitches. Hand always supplied with 98-100% blood after clamping of the radial artery. Subsequent lifting of the flap. Outgoing vessels are bipolarly coagulated or clipped. A total of 2 branches of the cephalic vein and a confluent vein as well as the radial artery can be dissected in the crook of the elbow. The flap is then removed. The veins are ligated or clipped. The artery is stitched with 6-0 Vascufil sutures. Flush the flap with heparin solution. The flap is then inserted into the defect and the stalk is passed through the tunnel. Suturing of the flap, initially with sutures. The flap can then be sutured into the ............................... defect, covering the entire area. The facial artery is prepared as a vascular connection. Likewise a vein that emerges from the stump of the internal jugular vein and the external jugular vein. First arterial anastomosis between the facial artery and radial artery. After opening the clamps, good arterial flow, good venous return. After conditioning the veins, a portion of the cephalic vein is first anastomosed with the external jugular vein using a 2.5 mm coupler. After opening the clamps, good venous flow, positive smear phenomenon. The other outgoing vein from the external jugular vein is lipped. The 2nd vein from the cephalic vein is also clipped. The confluence is prepared and anastomosed with the outlet from the internal jugular vein after conditioning the veins using a 2.0 coupler. After opening the clamps, good venous return, positive smear phenomenon. Subsequent careful hemostasis and irrigation of the wound area. Wound closure on the right with insertion of a Redon drain on the left and placement of 2 flaps. Insertion of an 8 mm tracheal cannula and suturing of this. The skin on the forearm is primarily closed cranially and split skin taken from the thigh is sutured caudally. Mepilex is then applied and a loose pressure bandage is applied using absorbent cotton. A Kramer splint is then applied and fixed in place with an elastic bandage. Attachment of the arm. The wound on the thigh is covered with a Mepilex dressing. The procedure is completed without complications. Patient goes to the intensive care unit for postoperative monitoring. Please continue antibiotics, which were started with Unacid, intraoperatively for 1 week. Please continue heparin perfusor, which was started intraoperatively, at 500 units per hour for 5 days. Check the vitality of the flap clinically and by Doppler. Left cervical suture marking for this purpose. Feeding via the inserted PEG tube for 10 days, then gruel or, if necessary, diet build-up. Overall cT2 to 3 oropharyngeal carcinoma on the left with cN2c status. Postoperative presentation at the interdisciplinary tumor conference after receipt of the final histology.