Initial inspection of the primary tumor region. There is an exulcerated mass on the right edge of the tongue, only the tip of the tongue is left out. Extensive submucosal growth. The tumor clearly reaches the midline approximately in the area of the middle of the tongue and also crosses it submucosally; tumor growth decreases again towards the base of the tongue. The basal base of the tongue towards the vallecula is tumor-free again. In addition, exophytic tumor growth over the glossotonsillar groove and circumscribing the posterior floor of the mouth onto the anterior palatal arch. In the anterior palatal arch, tumor cones at the mucosal level up to above the uvula cavity. The tumor can be palpated and moved in a cervical direction, therefore a primarily transoral approach was initially performed. Cut around the tumor and dissect using the electric needle and dissection technique, maintaining a safety distance of at least 1-1.5 cm. The lingual nerve can be kept straight, the lingual artery is ligated and removed. Macroscopic clear in sano removal with a clearly tumor-free covering soft tissue mantle on all sides, especially submucosally. This is followed by the removal of completely covering marginal samples at the mucosal level and the removal of largely covering marginal samples in the area of the tongue body. An in sano resection for the invasive carcinoma can be seen on all sides. In the frozen section diagnosis, only in the area of the glosstonsillar furrow, where the distance is actually macroscopically wide, is there still a circumscribed Cis. For this reason, a resection was performed and a new covering margin sample was taken, which again showed no tumor or dysplasia, so that a clear R0 situation can be assumed. Overall, this results in an extensive defect of the tongue with approx. 2/3 resection, especially in the area of the middle of the tongue body. The soft palate portion was resected basally together with a tonsillectomy. As a result, the tonsil lobe and the posterior floor of the mouth were circumscribed. Measurement of the defect for later defect reconstruction, in the meantime bilateral tracheotomy is performed. Start with the right side. Submandibular skin incision, cutting through skin and subcutaneous tissue, cutting through the platysma, exposing the sternocleidomastoid muscle, exposing the omohyoid muscle, exposing the submandibular gland and the digastric muscle. Removal of the anterior neck preparation and preservation of the superior thyroid artery of the hypoglossal nerve of the cervical anus. A narrow facial vein branch must be removed later during tunnel creation. Free preparation of the internal jugular vein, overall in level II and III some nodules of conspicuous size and configuration, but without surrounding infiltration. Clearing of the accessorius triangle and level Va with careful protection of the accessorius nerve and the cervical plexus branches. Finally, if the wound is dry, turn to the opposite side. Exactly the same procedure here, no macroscopically conspicuous nodes. The facial vein is preserved here, as is the external jugular vein on both sides. On the left side after evacuation of level IIa to Va. Wound irrigation with H202 and Ringer's solution. Insertion of a 10-gauge Redon drain and careful two-layer wound closure. Submandibulectomy is then performed on the right side and the tunnel is passed enorally. Widening of the tunnel, resection of the digastric muscle. Evacuation of level Ib with removal of further, macroscopically non-suspicious nodes. Ligation of the facial artery and after creation of a sufficient tunnel, later passage of the lifted graft to lift the antero-lateral thigh graft from the right. After marking the landmarks and doppler sonographic identification of the main perforator and two secondary perforators, the graft specially configured for the tongue edge/bottom of the mouth and tonsil region is marked. The graft measures a total of 16 x 7 cm. Medial incision due to the reconstruction of the entire length of the tongue up to almost the tip of the tongue. Identification of the rectus femoris muscle strictly subfacially. Dissection, identification of the vascular pedicle. Making the auxiliary incision. The supply of the graft through the ramus descendens is shown with a clearly visible fasciocutaneous course of the main perforator. Subfacial release. Incision of the graft involving the fascia lata. A narrow muscle cuff is left in the area of the outgoing main perforator. Isolation on the vascular pedicle. A strong accompanying vein with an additional narrower accompanying vein can be elevated so that the graft can then be placed under vital conditions. Careful wound inspection and hemostasis in the lifting area. Subsequent insertion of a 10-gauge Redon drain and careful multi-layer wound closure. The graft is then inserted under moderate tension. Due to the size of the defect and the graft, the conditions for insertion were considerably more difficult. Under laborious conditions, incorporation of the graft with an overall very good fit and complete coverage of the defect. After combined transoral and transcervical insertion, intact conditions on all sides. Pedicle positioning and conditioning of the pedicle vessels as well as the superior thyroid artery and the middle thyroid vein. Performing the arterial anastomoses with 8-0 Ethilon, revealing clearly vulnerable vessel walls with a large amount of vascular plaque, particularly in the area of the graft vessels. Clearly difficult adaptation conditions here. After initial anastomosis, there is no regular circulation. After opening the artery, ............... resection is seen. Careful excision of the anastomosis and repeat procedure. This is now sufficient and regular. Immediate regular venous return. Conditioning of the stronger flap vein and closure of the smaller one with sufficient venous outflow. Conditioning of the V. thyroidea media and insertion of the venous anastomoses with the coupler system using a size 3.0 coupler. Subsequently, with a positive smear phenomenon, regular pedicle position and regular flap vitality. Wound irrigation. Insertion of a size 10 Redon drain and careful two-layer wound closure. Finally, a plastic tracheotomy is performed. This involves a horizontal skin incision below the cricoid cartilage. Cut through the skin and subcutaneous tissue. Exposure and transection of the infrahyoid musculature. Exposure of the cricoid cartilage, exposure of the anterior surface of the trachea, transection of the slender thyroid isthmus. Due to the height of the larynx, insertion between the 1st and 2nd tracheal ring. Creation of a visor tracheotomy and insertion of the tracheostoma. Subsequent reintubation without difficulty to a size 8 low cuff cannula, which is suture-fixed. The procedure was then completed with a vital graft and no indication of complications. The patient received intraoperative intravenous antibiotics with Unacid, which should be continued for 24 hours postoperatively. Conclusion: Intraoperative R0 resected extensive cT3 cN2b tongue margin carcinoma on the right with extensive ALT reconstruction. Please abstain from food for at least 7 days, then the first swallowing diagnosis can be started if the flap is viable. Overall, a prolonged recovery of swallowing function can be expected due to the extensive defect. Presentation in our interdisciplinary tumor conference to determine the adjuvant therapy that is certainly indicated.