Induction of anesthesia and transnasal intubation by the anesthesia colleagues. First, tumor resection by <CLINICIAN_NAME>: The exophytic tumor is seen, which is located in the area of the tonsillar lobe, extends over the glossoalveolar groove to the base of the tongue, also runs towards the soft palate, but does not quite reach the border of the posterior palatal arch; the tumor extends caudally to below the tonsillar lobe. Now insertion of retractors or McIvor oral flaps alternately and suturing of the tongue. The tumor is successively incised macroscopically with a safety margin of at least 1 to 1.5 cm. Resection covers the posterior palate, anterior palate, lowest parts of the buccal mucosa at the border to the alveolar ridge, further along or above the alveolar ridge in the anterior direction, then via the glossoalveolar groove into the base of the tongue. Dorsocaudally, the resection extends over the posterior palatal arch to the adjacent pharyngeal side wall and finally just in front of the hypopharynx towards the base of the tongue and floor of the mouth. The floor of the mouth is also resected in the dorsal parts. The lingual nerve is located in the resection area and is also resected, as are the dorsal parts of the sublingual gland. The uppermost parts of the submandibular gland are also included in the preparation. Craniobasally, the resection extends in depth to the styloid process, which is exposed and the tumor is successively resected, taking the entire pterygoid musculature with it. The carotid artery is still palpable under the styloid process or under a thin soft tissue sheath and is not directly exposed. Finally, the entire tumor is removed and suture-marked in a typical manner. A marginal sample is taken cranially from the soft palate to the border of the alveolar ridge and also thread-marked. In addition, a marginal sample is taken anteriorly, which is also thread-marked and extends from the edge of the tongue to the alveolar ridge along the floor of the mouth. In the frozen section, despite ample safety margins of 1 to 1.5 cm, there are still in situ infiltrates or moderate to high-grade dysplasia in the area of the palatal arch, base of the tongue and along the alveolar ridge. Therefore, another marginal sample is taken medially on the pharynx with suture markings, as well as a marginal sample from the palate to the alveolar ridge with markings remote from the tumor and a marginal sample from the tongue area medially including caudal to the base of the tongue, also with suture markings here. Also a marginal sample from the alveolar ridge anterior lateral. No evidence of higher-grade dysplasia or invasive carcinoma in the marginal samples taken. Similarly, no carcinoma in the marginal samples taken at the beginning, also no invasive carcinoma or higher-grade dysplasia. Therefore, surgical R0 resection, although there is a suspicion that there may be a tendency towards field cancerization. Then perform PEG placement through <CLINICIAN_NAME> and <CLINICIAN_NAME> using the suture pull-through method. This is easily possible with good diaphanoscopy. Then sterile washing and draping and initial removal of the left arm. Perform the neck dissection on the right side through <CLINICIAN_NAME> and <CLINICIAN_NAME>. To do this, incise the skin in the usual way. Expose the borders. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Exposure of the submandibular gland. Showing the digastric muscle. Showing the cervical vascular sheath. Showing the hypoglossal and accessorius nerve. Exposure of the cervical sinus. Clearing of the neck levels IIa to Va while sparing the plexus branches. Insertion of a Redon drainage and two-layer wound closure. Then tracheotomy performed by <CLINICIAN_NAME>. For this, vertical skin incision, exposure of the pretracheal musculature. Exposure of the thyroid isthmus. Dissection of the thyroid isthmus. Creation of a visor tracheotomy between the 2nd and 3rd tracheal cartilage. Creation of a mucocutaneous anastomosis. Then neck dissection on the left side by <CLINICIAN_NAME>. Incision in the usual manner. Exposure of the sternocleidomastoid muscle, exposure of the submandibular gland. Exposure of the cervical vascular sheath and the omohyoid muscle. Exposure of the accessorius nerve and hypoglossus. Clearing of neck levels IIa to Va while sparing the plexus branches. Then removal of the submandibular gland on the left side, which was already partially resected during the tumor resection and creation of a 3 QF wide tunnel to the inside of the mouth. Parallel to this, lift the radialis graft from the left by <CLINICIAN_NAME> and <CLINICIAN_NAME>: mark the flap in the appropriate size and three-dimensional configuration, also in the direction of the pedicle. Then first lift the radial flap from the ulnar side and extend the incision cranially. Identification of the superficial venous system and the deep flap pedicle. Then recut the flap also from the radial side. This is done under constant pulse oximeter control, no special features here. The flap is also perfused. Then locate the pedicle. Deposition of the pedicle. This is treated distally and cranially with 4-0 Prolene puncture ligatures. The flap is then lifted along the pedicle in the typical manner, the outgoing vessels or outgoing vessels from the musculature are clipped successively. Dissection of the pedicle up to the crook of the elbow. Here the cephalic vein with 2 good outlets as well as a good confluence and the radial artery can be dissected. It can be seen that the radial artery graft is no longer perfused. Then puncture in the skin area. There is no blood flow and no detectable pulse signal in the area of the flap by Doppler sonography, only the proximal 2/3 of the flap stalk is still detectably perfused by Doppler sonography. The flap is then immediately warmed with warm cloths. As the flap still showed good perfusion in the proximal pedicle area, the decision was made to anastomose it arterially at the neck. Now anastomosis between the radial artery and the superior thyroid artery through <CLINICIAN_NAME>. The thyroid artery showed very good blood flow. Unfortunately, even now there was no graft perfusion and there was also no vernal return flow. Especially spasm of the flap. As a last resort, the flap was placed in a solution of lidocaine, sodium bicarbonate and nitroglycerin and later sprayed again with nitrospray. When these measures proved ineffective, the decision was made to remove the flap and perform an endoscopy of the radial artery with a 0.8 mm endoscope from proximal and distal. Overall unclear situation. Explanation by the scar described by the patient, which was described as a superficial injury, not sufficient. Filiform openings are found at the upper entrance to the flap. In this case, anomaly of the vessel or consequence of an injury. A major trauma is not known from the anamnesis and was not described by the patient when asked. Nonetheless, there is evidence of insufficient flap perfusion at the upper border of the flap or at the upper edge of the flap where the artery enters. At the site of the filiform vascular drawings, the artery is now dissected out in the fatty tissue. It can also be seen here that the artery is lost in filiform, smaller vessel lumina. This means that the blood supply to the flap in this region is interrupted. The forearm is closed in a typical manner using split skin from the right thigh. Due to the defect, the only remaining option is to elevate the radial flap on the opposite side in order to cover the defect in an adequate, three-dimensional and areal dimension. Therefore, after covering the right side of the arm, lift the radialis flap from the right: Here too, after marking the flap, proceed in the same way as on the opposite side. As on the opposite side, a superficial venous system and the connection to the deep venous system as well as the deep vascular system of the flap pedicle can be visualized. Here too, first dissection from the ulnar, then from the radial side. Here too, the lateral antebrachial cutaneous nerve is preserved as on the opposite side. Separation of the flap distally with puncture ligation, as on the opposite side, and dissection cranially with supply of the outgoing vessels using clips or bipolar or ligature. At the end, 2 cephalic veins and a good radial artery. After removal of the flap, the veins are supplied with ligatures. The artery is supplied via puncture ligatures. Blood flow to the hand is always very good until the end with saturation values of 99 to 100 %. Very good blood supply to the flap. Ample irrigation of the flap pedicle with heparin solution. No special features here either. Subsequent closure of the forearm with split skin from the right thigh. The graft from the right side is regularly perfused and completely unremarkable. The graft is then removed, rinsed with heparin and prepared for insertion into the oropharynx. The tunnel must be widened slightly for this, as there is not yet sufficient visibility from the transcervical side into the defect. Suturing is almost impossible as the tongue and cheek area are extremely swollen and the patient already has a very small mouth opening. Therefore, the graft is first sutured to the soft palate and to the lateral wall of the oropharynx from the transoral side and the rest from the transcervical side in the area of the medial pharyngeal wall and around the base of the tongue. Then turn the graft over and suture in the area of the alveolar ridge and the floor of the mouth again from the transoral side. Then prepare the facial artery to attach the graft, which had already been ligated beforehand. The flow is very good. Anastomosis with the facial artery and a stump of the internal jugular vein to the deep flap vein and then anastomosis between the facial artery stump and the cephalic vein. Positioning of the pedicle. Fixation of the pedicle with Gelita. Insertion of a Penrose drain and two-layer wound closure, completion of the procedure. The patient is ventilated and admitted to the intensive care unit. Please continue antibiotics for at least 24 hours. Wait for histology and presentation of the patient at the tumor conference. A blue swallow can be performed clinically from the 10th postoperative day. An X-ray pre-swallow is not necessary.