This is followed by the PEG insertion. Insertion of the esophagoscope into the stomach. There, during spontaneous diaphanoscopy, insertion of a 15 mm abdominal wall probe without complications. Fixation to the abdominal wall in the typical manner. Subsequent transoral tumor resection: tumor is resected on all sides with a safety margin of 1-1.5 cm. Half the tongue is removed. The floor of the mouth is also resected across the midline in the area of the caruncle to the right. The body of the tongue is resected beyond the midline to the right. Resection extends deep into the base of the tongue and also includes parts of the glossoalveolar groove and the beginning of the pharyngeal wall. The lingual nerve is also resected. A. lingualis is ligated. The preparation is thread-marked for the frozen section. No tumor formations in the area of the mucosal margins. In the resection margin basal to medial lateral scarce resection margins, therefore an extended resection of the remaining muscles of the floor of the mouth, external tongue muscles, tongue base muscles and also muscles from the opposite side is obtained. The specimen is suture-marked (sutures remote from the tumor) and sent for frozen section, where there are no more tumor infiltrates. Thus R0 resection. Subsequent repositioning and sterile draping of all surgical areas. Neck dissection left: Skin incision in typical manner. Exposure of the sternocleidomastoid anterior margin. Exposure of omohyoid muscle, digastric muscle. Exposure of the internal jugular vein, internal carotid artery, external carotid artery, superior thyroid artery. N. vagus is visualized as well as N. accessorius and N. hypoglossus. In the cranial area level II a bulging mass. This shows secretions similar to a neck cyst. No definite lymph node metastasis. Level II-V is evacuated in a typical manner and the branches of the cervical plexus are also preserved. Careful hemostasis. Exposure and preservation of the facial artery from below. The external jugular vein is separated cranially and initially ligated and preserved. Neck dissection on the right is then performed in the same way. Here level II-V evacuation by <CLINICIAN_NAME>. Subsequent tracheotomy by <CLINICIAN_NAME> and <CLINICIAN_NAME>. Small Kocher's collar incision. Exposure of the infrahyoid musculature. Splitting of these. Exposure of the thyroid isthmus, undercutting of this, clamping, severing and treatment using puncture ligatures. Subsequent visualization of the trachea. Entering the 2nd/3rd intercartilaginous space. Creation of a modified Björk flap with a wide base. This is epithelized in the typical manner. Subsequently reintubation and insertion of a size 8 tracheal tube, which is fixed with sutures. Then after measuring the defect, which is 11 x 6-7 cm. Mark the size and shape of the flap on the left forearm. Then first lift the flap subfascially from the ulnar side. Then extend the incision into the crook of the elbow. Expose the superficial venous system and connection to the deep venous system. Subfascial elevation of the superficial venous system. Subsequent elevation of the flap subfascially from the radial side. Exposure and preservation of the lateral antebrachial cutaneous nerve. Subsequent exposure of the radial artery. After clamping and waiting, no change in the saturation of the hand, which is always 100% in this case. Deposition of the radial artery. Successive elevation of the radial artery flap with ligation or bipolar coagulation or clipping of vessels. The vascular pedicle is dissected up to the antecubital fossa. Good confluence can be visualized here. Connection to the superficial venous system. A large cephalic vein with ends on the superficial venous system. Finally, the flap is removed. Veins are ligated. Confluence is additionally clipped. The interosseous artery is clipped after waiting for saturation. The radial artery is treated at the entrance to the brachial artery using 6-0 Vascufil sutures. The flap is flushed with heparin and preserved. In the forearm, after extensive hemostasis, the skin is first closed proximally in the typical manner and a Redon drain is inserted. A piece of split skin is then removed from the thigh with the dermatome in the typical manner. Hydrocolloid dressing is then applied. Split skin is worked into the defect. Here complete tension-free defect coverage. Relief incisions. Application of swabs. Application of octenidine gel and Mepilex. The arm is then covered with compresses and wrapped in absorbent cotton. Application and fitting of a Cramer splint. This is fixed in a functional position with a tape bandage. Hand is in 100% saturation. Subsequent positioning of the arm. Radialis flap is successively worked into the defect with 3-0 Vicryl single button sutures. The pedicle is inserted anteriorly in the area of the defect. The digastric muscles were also cut from below. Other parts of the muscles of the floor of the mouth, including the submandibular gland, were also removed to enlarge the tunnel. The submandibular gland was removed because the sublingual gland and the entire wharton's duct were also resected, as was the lingual nerve. All removed parts of the floor of the mouth muscles and the submandibular gland are preserved and sent for histology as another final marginal sample. The mucosa in the right floor of the mouth area is incised and the Wharton's duct is incised and marsupialized. The flap is sutured over here in the typical manner. After the flap has been completely sutured without tension and the pedicle has been passed into the soft tissues of the neck, the facial artery is selected, as the lumen of the superior thyroid artery is too small for connection to the radial artery. The radial artery is anastomosed with the facial artery after conditioning with single 9-button Ethilon sutures. Opening of the clamps, good arterial flow, good venous return. The V. thyroidea media and a further outlet for the venous anastomosis are then prepared and conditioned, as are the V. cephalica and an outlet of the confluence. After conditioning, the confluence is anastomosed to the small outlet from the V. thyroidea media using a 1.5 mm coupler. After opening the clamps, good venous return, positive smear phenomenon. The larger outlet from the V. thyroidea media is then anastomosed with the V. cephalica using a 2.5 mm coupler. Again, good venous return after opening the vein. Positive smear phenomenon. Subsequent careful irrigation of the wound area. Careful hemostasis. Layered wound closure on the left with 2 flaps. Skin closure on the right in the neck area with insertion of a Redon drainage. Check the flap again, it is well perfused. Severe swelling in the mouth area. Patient goes to the intensive care unit postoperatively ventilated. Please continue antibiotic treatment with Unacid, which was started intraoperatively, for one week. Nutrition via the inserted PEG tube. This should be loosened the following day. Thereafter, if necessary, nutrition via the PEG tube. Food build-up after 7-10 days at the earliest, depending on the flap situation. If necessary, swallow porridge. Check the flap transorally. A suture marker is placed for Doppler control. Check the flap according to the schedule for 5 days. Heparin perfusor 500 E/h was started intraoperatively, please continue this for 5 days. Overall cT3-4 carcinoma of the floor of the tongue extending into the base of the tongue. Defect covered by radial flap. The left cervical mass in level II may be a neck cyst or a lymph node metastasis with necrotic contents. In this case, however, the macroscopic aspect is atypical. Presentation after receipt of the final histology in the interdisciplinary tumor conference.