First, perform the PEG insertion. For this purpose, insertion with the gastroscope under laryngoscopic control. Easy pre-scanning into the stomach. Here, with good diaphanoscopy, problem-free puncture of the stomach and insertion of the PEG tube using the usual thread pull-through method. Inspection of the oesophagus on reflection. No suspicious lesions here. Now enter with the small bore tube and inspect the primary tumor with the small bore tube and the open mouth retractor. There is an exophytic growing tumor in the area of the right anterior palatal arch, passing over the glossotonsillar groove to the base of the tongue and clearly infiltrating it in depth, affecting at least 1/4 of the base of the tongue, but free vallecula and epiglottis caudally. No growth towards the hypopharynx. The tumor extends over the glossotonsillar groove onto the alveolar ridge and is located here coarsely and not displaceable. In this case, the tumor tends to grow submucosally and nodularly and is located at least 3 cm above the mandible. Urgent suspicion of mandibular infiltration here. Tumor extends anteriorly in a bumpy shape. A screening specimen was taken at the anterior margin for frozen section diagnosis. However, no tumor growth here. Now consult <CLINICIAN_NAME> and discuss the case. Confirmation of the overall clear tumor progression and the high degree of suspicion of mandibular infiltration. Therefore, after detailed case discussion, decision to consult the maxillofacial surgeons. Findings demo and case discussion by telephone to <CLINICIAN_NAME>. Confirmation of suspected mandibular infiltration. Primary treatment recommendation of continuous partial mandibular resection. Joint case discussion again with <CLINICIAN_NAME>. Due to the thinning and lack of adequate curative treatment options for surgical restoration, the decision was made to perform primary surgical restoration with the recommended partial mandibular resection and reconstruction using a scapula flap. Neck dissection and tracheotomy performed first. Start with the neck dissection on the left side: no suspicious masses are described sonographically. Skin incision on the anterior edge of the sternocleidomastoid muscle. Cut through skin and subcutaneous tissue. Dissection of the platysma. Creation of a platysma flap. Exposure of the external jugular vein. Exposure of the sternocleidomastoid muscle, the omohyoid muscle, the submandibular gland and the digastric muscle. Clearing out the anterior neck level while carefully protecting the superior thyroid artery, the hypoglossal nerve and the cervical sinus. Now expose the internal jugular vein. Free preparation of the vein after prior exposure of the accessorius nerve. Exposure and preservation of the facial vein, the external vein was ligated and removed in the course of the oblique pulling exit. Clearing of the accessorius triangle and level V with careful protection of the cervical plexus branches and special protection of caudal lymphatic structures. Dry conditions here. Final inspection and in dry conditions, after final palpation of level Ib and inconspicuous conditions, wound irrigation with Ringer's solution and two-layer wound closure after insertion of a 10-gauge Redon drain. Now turn to the neck dissection on the opposite side: here sonographically 2 suspicious masses level II to IV. In principle the same procedure. Dissection of skin and subcutaneous tissue, dissection of the platysma, creation of a platysma flap. Exposure and preservation of the external jugular vein. Exposure of the sternocleidomastoid muscle. This can be removed from the nodular metastatic lesions measuring up to 3 cm on the internal jugular vein. No evidence of muscle infiltration here. Visualization of the omohyoid muscle. Expose the submandibular gland and the digastric muscle. Clearing of the anterior neck preparation with careful protection of the superior thyroid artery, cervical artery and hypoglossal nerve. There is no real facial vein here, but there is a very strong superior thyroid vein. Free dissection of the internal jugular vein, including the suspicious lesions. Careful dissection in the area of the vein. Clearly no infiltration of the vessel here, but vulnerable conditions. Outlets close to the vein must be ligated twice. Otherwise problem-free evacuation. Exposure of the accessorius nerve. Evacuation of the accessorius triangle and evacuation of level V with careful protection of the plexus branches. Further exposure of the external carotid artery. Exposure of the outlet of the upper laryngeal bundle and the facial vein. Now, due to the expansion, evacuation of level Ib. This is done with the submandibular gland. Careful subcapsular dissection while keeping the branch of the mouth away. Careful dissection and protection of the facial artery. A lymph node measuring a good 1 1/2 cm anterior to the gland is noticeable, otherwise no macroscopically suspicious changes in level Ib. Palpation of the floor of the mouth. No changes here. Now, with dry wound conditions, first turn to the tracheotomy. Make a horizontal incision below the cricoid cartilage. Cut through the skin and subcutaneous tissue. Expose and ligate the strong anterior jugular vein in this area. Exposure of the infrahyoid musculature. Dissection of the musculature, exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. Bipolar coagulation of the thyroid isthmus and, after complete exposure of the anterior tracheal surface, insertion between the 2nd and 3rd tracheal ring. Creation of a broad-based pedicled Björk flap and insertion of the tracheostoma in the usual manner. Subsequent problem-free transfer to an 8 mm tracheoflex cannula and fixation of the cannula with suture. Now use <CLINICIAN_NAME> from maxillofacial surgery until osteocutaneous fixation of the graft. The mandibular branch is now sharply visualized. If the course of the mandible is tortuous, remove the facial artery as distally as possible to obtain a strong vascular stump and expose a large area of the mandibular branch ............ of the periosteum and muscle insertions. Exposure of the ascending mandibular branch up to the joint, complete freeing of the mandibular branch from the muscle processes. Now, after complete exposure, saw out approx. 6 cm of mandible after previous fixation with 2.7 from the synthesis plate, which is fixed with 12 and 14 screws. Sawing out the bone portion. This results in a circumscribed detachment of bone in the area of the mandibular angulus. This is later refixed with osteosynthesis and screws. Re-release of the plate. Therefore creation of a wide access. Entering enorally in the area of the anterior floor of the mouth. Successive resection of the tumor, taking the lateral floor of the mouth and the edge of the tongue completely up to the base of the tongue. Here, generous resection with resection of approx. 1/3 of the base of the tongue. Macroscopically and palpatorily clearly healthy. Resection towards the soft tissues of the cheek well within the healthy tissue. Resection of the tumor including the anterior palatal arch and the tonsil as far as the parauvular region, but sparing the posterior palatal arch. After caudal resection up to just before the epiglottis and also here resection of the tumor clearly in healthy tissue. Now, after extirpation of the tumor, a clear in sano resection can be seen macroscopically. Only in the area of the anterior floor of the mouth macroscopically somewhat scarce resection. Therefore, a strong resection is performed in the area of the anterior floor of the mouth. Finally, the tumor area is completely covered with continuous margin samples. These are sent for frozen section diagnostics and assessed here as completely free of tumor and dysplasia. Therefore, after meticulous hemostasis, sterile packing of the wound conditions and repositioning to elevate an osteomyocutaneous scapula flap. A separate dictation from <CLINICIAN_NAME> from the MKG follows. After removal of the graft, preparation of the vascular pedicle. Successive fitting of the bony part. Difficult conditions here, but finally good fitting in the area of the bony margins. After osteosynthetic treatment, insertion of cancellous bone tissue. Final firm fit. Previous transcervical suturing of the cutaneous part in the area of the base of the tongue and the caudal pharyngeal defect as well as beginning in the area of the posterior palatal arch. Attempt to complete the cutaneous suture transorally. This is not successful due to increased tension. Therefore, renewed anterior loosening of the plating. In the meantime, renewed demonstration of findings at <CLINICIAN_NAME> and <CLINICIAN_NAME>. With good mobilization of the cutaneous part, problem-free transoral insertion of the graft. Finally, complete defect coverage in the area of the mucosal defect. In the area of the anterior floor of the mouth and the tongue, primary mucosal adaptation is described here, finally also palpably completely dense conditions. Repositioning of the plating. Renewed screwing. Insertion of spongiosis, circumscribed, and attention to microvascular anastomization: For this purpose, initially further exposure of the vascular pedicle. Clipping of vessels close to the stalk. After dissection, positioning of the detached facial artery with approximate caliber equivalence. Excellent flow after free dissection and placement. Free preparation of the vessel and now, after placement, perform end-to-end anastomosis with 8.0 ethinol. This is somewhat more difficult with vessels that are not exactly the same caliber, but is ultimately successful. Initially delayed venous return. After a short run-in phase, however, excellent reflux conditions with enorally regular flap perfusion. Now, after positioning of the arterial anastomosis, the best possible placement conditions for anastomization with the external jugular vein. Therefore, free preparation of the external jugular vein. Deposition after ligation. Free preparation. Measurement of a 3.5 mm coupler and problem-free execution of the coupler anastomosis. After opening the Acland clamps, immediate regular venous filling and excellent flap perfusion. Finally, circumscribed hemostasis in the area of the previously thinned muscle cuff and, in dry conditions and with good flap vitality, careful two-layer wound closure with moderate tension conditions. Due to the large area of exposed musculature in the area of the muscular graft part, the caudal part is left open cervically. Insertion of a flap and suturing and termination of the procedure at this point. Conclusion: Due to the high degree of suspicion of mandibular infiltration and the lack of equivalent curative treatment options, resection of a cT4a cN2b oropharyngeal carcinoma on the right with continuity resection of the mandible and reconstruction of the osseous defect as well as reconstruction of the enoral defect with an osseomyocutaneous scapular flap. Due to the extent of the tumor, adjuvant therapy is certainly required. The patient received intraoperative intravenous antibiotics with Unacid 3 g. Please continue this postoperatively with Unacid 1.5 g for 3 days. Postoperatively, please monitor the flap meticulously according to the known scheme. Please visit the maxillofacial clinic approx. 1 week postoperatively for an X-ray overview. From the 8th postoperative day, endoscopic check-up and, if flap vitality is normal and the conditions are dense, a clinical swallowing test and, if necessary, oral food preparation. Decannulation if necessary, depending on the diet.