Induction of anesthesia and intubation by anesthesia colleagues. First PEG insertion in the usual manner using the thread pull-through method. In this case, PEG insertion is successful with good diaphanoscopy. Insertion of the spandex and looping of the tongue and inspection of the tumor. The tumor is located on the right side wall of the oropharynx, starting at the anterior palatal arch and passing onto the tonsil as well as at the edge of the base of the tongue on the right. The mucosa around the tumor is incised with a monopolar needle and then the tumor is successively removed with scissors and bipolar forceps as far as possible from the upper transoral area. The tumor itself extends very far laterally into the soft tissues of the neck, so the remaining part must then be removed transcervically. Start with the neck dissection on the left side. Skin incision in a preformed skin fold across the neck, three transverse fingers below the lower jaw. Initial exposure of the platysma. Formation of a platysma flap cranially. Exposure of the sternocleidomastoid and the omohyoid, the cervical vascular sheath and free preparation of the internal jugular vein. Resection of the neck block II to V, sparing the plexus branches and the hypoglossal nerve as well as the facial vein. Removal of the submandibular gland and transection of the digastric muscle to gain access to the oropharynx. Residual resection of the tumor and formation of an enoral bridge. The tumor is sent for final histology and samples are taken from all the margins for frozen section without the pathologist being able to find carcinoma or carcinoma in situ. Neck dissection is performed on the right side. For this purpose, a transverse skin incision is also made on the neck. Exposure of the platysma. Formation of a platysma flap. Exposure of the sternocleidomastoid and omohyoid. Exposure of the cervical vascular sheath. Free preparation of the internal jugular vein. Removal of the neck preparation II a to V a, sparing all nerves and vessels except for the external jugular vein, which is ligated. The submandibular gland is left on this side. Despite everything, level I is also removed on both sides, as the tumor has partly spread to the anterior floor of the mouth. Repositioning to elevate the radialis graft. Marking of the graft and the skin incision. A 5 x 7 cm incision is made around the graft. First dissection of the venous plexus in the crook of the elbow. A good superficial and deep venous system with a relatively weak confluence can be seen. Then visualization of the brachialis muscle and the superficial venous system. Integration of a superficial vein into the graft. Exposure of the superficial ramus, radial nerve. Exposure of the radial artery and repositioning of this. Lifting of the radialis graft first from the lateral, then from the medial side. Dissection of the pedicle with clipping or bipolar coagulation of outflows. Deposition of the graft in the crook of the elbow, leaving one superficial and one deep vein for the connection. Insertion of the graft into the oropharynx and suturing of the graft from the soft palate and transcervically into the oropharynx. Suturing is extremely difficult as the tongue is very swollen and must be done mostly transcervically. Repositioning for anastomosis of the vessels. First dissection of the superior thyroid artery as the connecting vessel from the neck. Dissection of the radial artery on the graft and anastomosis of this. This has to be performed twice, as the flow was too low the first time, but the second time the blood flow to the graft was satisfactory with clearly good return flow in both graft veins. For this, the facial vein is taken once and another small accompanying vein, both of which are anastomosed using a coupler. Positioning of the pedicle with the help of Gelita and insertion of a Redon drain on both sides as well as two-layer skin closure. A tracheotomy is performed in the usual manner using the visor technique at the same time as the forearm is being sutured. Skin incision below the cricoid cartilage. Dissection down to the musculature. Pushing the muscles aside. Exposure of the thyroid gland. Separation of the thyroid isthmus. Exposure of the anterior wall of the trachea. Insertion between the second and third tracheal cartilage. Formation of a mucocutaneous anastomosis in the upper and lower part. Removal of the full-thickness skin from the groin in the usual manner. Insertion of a Redon drain in the groin and two-layer wound closure. The full-thickness skin is thinned and transplanted to the defect on the arm. On the arm, adaptation of the wound edges in the upper part. The full-thickness skin is sutured into the defect area with single button sutures. Perforation of the full-thickness skin and application of a VAC dressing. Apply a pressure of 75 mm Hg to the VAC dressing. Re-intubation and transfer of the patient to the intensive care unit on mechanical ventilation. Continue antibiotics for 24 hours. Regular daily graft checks and clinical diet build-up, without X-ray emesis, on the 10th postoperative day. Presentation of the patient at the tumor conference after receipt of the histology.  