First start with the PEG insertion. Entering with the gastroscope under laryngoscopic control. Easy pre-scanning into the stomach. If diaphanoscopy is good and the stomach has been punctured without any problems, the PEG tube is inserted using the usual thread pull-through method. After repositioning the patient, turn to pharyngoscopy and inspect the primary tumor. There is an exophytic process in the area of the right tonsil, which partially reaches the soft palate via the anterior palatal arch and the posterior palatal arch. Right-sided subtotal infiltration and consumption of the uvula. Infiltration of the base of the uvula on the left side, macroscopically on the right side, right caudally, not exceeding the tonsil lobe, also palpatorily no indication of deep infiltration in the cervical direction. The tumor is now resected with partial soft palate resection with a safety margin of approx. 1.5 cm. Release of the tumorously altered tonsil with lateral preservation of a soft tissue mantle. Complete removal of the posterior palatal arch, also here removal of muscles on all sides. Deposition at the lower tonsil pole. Inspection reveals a macroscopically and palpatorily clearly resected tumor in sano. The specimen is thread-marked on all sides for frozen section diagnostics and is diagnosed here as a squamous cell carcinoma resected in sano. Inspection of the defect. There is a clear soft palate in the defect. Approximately 2 cm of the soft palate have been subtotally resected. Subtotal resection of the posterior palatal arch so that the defect in the area of the tonsillar lobe is resected. Measurement of a 0.5 x 4.5 cm graft with separate logging for the soft palate. The neck is first dissected on the left side. To do this, cut through the skin and subcutaneous tissue along the sternocleidomastoid muscle. Exposure and dissection of the platysma. Creation of a platysma flap. Exposure and preservation of the external jugular vein, which is very slender here. Exposure of the sternocleidomastoid muscle. Exposure of a strong transcervical vein. Exposure of the omohyoid muscle. Exposure of the submandibular gland and the digastric muscle. Release of the anterior neck preparation with careful protection of the superior thyroid artery as well as the cervical artery and the hypoglossal nerve. A very strong anterior jugular vein can be seen here. A true facial vein is not present here. Some of the sides of the anterior jugular vein are ligated, but overall it is preserved as a vessel. The vein takes up the submandibular region via the lateral branches. The branches are also preserved here. Complete exposure of the digastric muscle. Exposure and free preparation of the internal jugular vein while carefully preserving the vessel. Exposure of the accessory nerve. Level 2 shows a hardened palpable lymph node measuring approx. 2.5 x 1.5 cm on the internal jugular vein. Macroscopically quite suspicious, but without perinodal and nodal growth. Finally, evacuation of the accessorius triangle with careful protection and evacuation of level 5 with careful protection of the cervical plexus branches as well as caudal dry conditions without lymph vessel alteration. Final wound inspection with dry conditions on palpation. No further masses, no bleeding. Wound irrigation with Ringer's solution and after insertion of a 10-gauge Redon drainage, careful two-layer wound closure. The neck dissection of the right side is now carried out in parallel and the radialis graft is lifted for neck dissection. Basically the same procedure as on the opposite side. Cut through the skin and subcutaneous tissue along the anterior edge of the muscle. Expose and cut through the platysma. Exposure and preservation of the external jugular vein and auricular nerve. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Visualization of the submandibular gland. Exposure of the digastric muscle. Removal of the anterior neck preparation, carefully preserving the superior thyroid artery, the cervical artery and the hypoglossal nerve. Exposure of the accessorius nerve. Dissection of the internal jugular vein. The size and shape of the lymph nodes are conspicuous in level 2 and in the transition to level 3, so that the cN2c neck status can be confirmed intraoperatively. Clearing of the accessorius triangle with careful protection of the nerve. Evacuation of level 5 with careful protection of the cervical plexus branches. There is also no true facial vein on the right side. Strong upper thyroid branch. This is prepared for later anastomization, and the superior thyroid artery is also dissected, although it is relatively slender, so the faciliac artery is also prepared. The carotid artery is now dissected cranially after removal of the digastric muscle. Dissection up to the styloid, then the pharyngotomy can be performed in the area of the tonsillar lobe by transoral control. Widen the pharyngotomy, taking the surrounding muscles with it. This results in a tunnel a good two transverse fingers wide. Now to lift the radialis graft. After marking the graft, identify the radial artery by palpation and the cephalic vein. Perform the tourniquet. Cut around the graft. Radial start. Exposure of the cephalic vein. Exposure of the brachialis muscle. Exposure of the Haydn maneuver. Exposure and securing of the superficial ramus, radial nerve. Exposure of the distal vascular pedicle. Blunt cutting of the vascular pedicle distally after ligation, strictly subfascial release. After complete exposure of the brachioradialis muscle with isolation and removal of the cephalic vein. Inappropriate dissection, exposure and dissection of the flexor carpi ulnaris muscle. Exclusion of a superficial ulnar artery. Complete release of the graft with careful clipping of outgoing vessels. Isolation on the vascular pedicle with the radial artery and accompanying veins as well as additional elevation of the strong cephalic vein. Expose a strong bridge of the accompanying veins to the cephalic vein and, if the accompanying vein is relatively confluent, take the bridge branch and isolate it on the cephalic vein after clipping the remaining branches of the outgoing veins. Exposure of the branch of the radial artery. Exposure of the outlet of the anterior interosseous artery and the powerful ulnar artery. Both vessels are left intact and spared. Re-opening of the tourniquet with uterine hemostasis with a vital, regular graft and regular blood supply to the hand. Finally, after careful hemostasis in the case of a vital graft, the graft is removed. Subsequent careful two-layer wound closure. Removal of the full-thickness skin graft from the groin and final application of a vacuum sealing bandage and the cramp splint in the functional position and repositioning of the arm. For full-thickness skin harvesting from the groin on the right, mark a full-thickness skin graft measuring a good 10 x 5 cm. Cut around the skin with strict cutaneous elevation. Careful subcutaneous mobilization. Meticulous hemostasis and careful multi-layer wound closure under moderate tension after insertion of a 10-gauge Redon drain. The radialis graft is now inserted transcervically. Gradual insertion of the graft under soft palate reconstruction and doubling of the graft. Careful insertion of the tonsil lobe. Finally, dense conditions and good adaptation conditions. Microscopic conditioning of the pedicle vessels, very strong radial artery and strong cespal vein. First conditioning of the superior thyroid artery. A very slender vessel can now be seen here, even after removal, so that the superior thyroid artery is clipped. Dissection of the facial artery. ......... of the vessel. Moderate difference in caliber with further caliber advantage of the radial artery. Conditioning of the vessels and successive caliber-adapted anastomization with 8.0 Ethilon, this is laborious, but finally succeeds well and adequately with immediate regular venous return and regular flap perfusion. Now conditioning of the superior thyroid vein in order to achieve some degree of caliber equivalence, this must be placed relatively close to the internal jugular vein. Measure a coupler of size 3.0 and perform the venous anastomosis with the coupler. Immediate regular venous return after reopening of the artery, regular perfusion with regular pedicle pulsation and good graft perfusion. Multiple inspections. Enoral conditions remain lean, therefore a defect limited to the tonsillar lobe and the soft palate is avoided, a tracheostomy is not performed and the procedure is terminated after the patient has been repositioned. The patient received intraoperative i.V. antibiotic treatment with Unacid 3 g. This should be continued for 24 hours and a single-shot administration of 250 mg SDH to prevent swelling. Conclusion: Intraoperative R0 resected cT2 cN2c oropharyngeal carcinoma on the right. From the 8th postoperative day onwards, with a properly healing graft and dense conditions, a gradual increase in diet is possible. Postoperatively, please monitor the flap meticulously by enoral inspection. Note: On the right cervical side, the course of the pedicle is relatively close to the subcutaneous level of the carotid bulb. Please strictly avoid pressure bandages here and exercise caution when opening if necessary.