First, pharyngoscopy and laryngoscopy again after nasotracheal intubation of the patient by the anesthesia colleagues: The exophytic tumor is seen, which extends to the glossoalveolar groove laterally at the back, infiltrating under the floor of the mouth in the direction of the submandibular space. Infiltration also towards the base of the tongue and here the midline is reached but not crossed. Overall indication for tumor resection, neck dissection and coverage with a radial flap. The apron flap is lifted first and a tracheostoma is created. Tracheotomy: Horizontal incision just below the cricoid cartilage. Cut through the skin and subcutaneous tissue. Identification of the infralaryngeal musculature and division of the musculature in the midline. Push the musculature to the side and identify the cricoid cartilage. Sharp dissection of the cricoid cartilage and undermining of the thyroid isthmus. Bipolar coagulation of the thyroid isthmus and transection of the same. Identification of the anterior wall of the trachea. Careful removal of tissue from the anterior wall of the trachea. Tracheal incision in the 2nd to 3rd intratracheal ring space and creation of an epithelialized tracheostoma in the usual manner. Re-intubation with the 8-bore tracheostomy tube. PEG insertion: PEG insertion using the thread pull-through method. This is successful without any problems if the diaphanoscopy is positive. Tumor resection: First of all, cervical exposure of the cervical vessels as well as the hypoglossal nerve and vagus nerve. Snaring of these structures using Vessel-Loups. Vessels are dissected away from the soft tissue as far as the cranial side. The digastric muscle is severed and cut laterally and then resected at the lateral end. The mandible is exposed after pushing the soft tissues including the branch of the mouth cranially. The entire soft tissue is pushed away from the mandible with the periosteum from the angulus to the symphysis. Infrahyoid muscles are detached from the hyoid bone and dissected as a Remmert flap pedicled to the superior thyroid artery and the cervical artery and beaten downwards. The hyoid bone is then resected in the midline and included in the tumor resection together with all overlying soft tissue. The entire external musculature is resected in the midline. The entire dorsal body of the tongue, including the floor of the mouth and the largest parts of the sublingual gland, is resected transorally, except for the tip of the tongue. Resection also includes the areas of the tongue beyond the midline from the body of the tongue to the base of the tongue. The periosteum is also removed transorally from the lower jaw, the entire soft tissues and muscles of the floor of the mouth are also resected. The lingual nerve is also resected. In the further course of the operation, the hypoglossal nerve is also resected medial to the exit of the cervical nerve. The tumor is clearly resected macroscopically in healthy tissue and removed in toto. Multiple suture markings are made on the tumor, which is sent to the frozen section. Marginal samples of the mucosa are taken from the alveolar ridge to the floor of the mouth at the front, a further marginal sample of the mucosa from the middle of the tongue to the body with underlying soft tissue and soft tissue basally on the rest of the hyoid bone. All marginal samples and the marked tumor are sent for frozen section. Here, tumor in healthy tissue as well as marginal samples, thus R0 resection. Careful hemostasis and irrigation of the wound area and resection areas. The lingual artery and facial artery were already prepared as possible vascular anastomoses during the resection. The superior thyroid artery was included in the Remmert flap. Neck dissection on both sides by <CLINICIAN_NAME>: skin incision and dissection through the subcutaneous fatty tissue. Subplatysmal dissection of the apron flap. Beginning on the right side. Exposure of the anterior border of the sternocleidomastoid muscle and dissection in depth. Finding the accessorius nerve and exposing it. Dissection of the omohyoid muscle and finding the submandibular gland. Elevation of the submandibular gland and protection of the marginal ramus. Exposure of the posterior venter of the digastric muscle up to region II b. Now expose and locate the accessorius nerve and protect it. Dissection of the internal jugular vein and its multiple outlets, including the facial vein. These are initially preserved, but then turned downwards to serve later as possible connecting vessels. Dissection of the jugulofacial angle and removal of multiple conspicuous lymph nodes. Protection of the hypoglossal nerve. Now dissection of the lateral neck preparation in regions II to V, sparing the vagus nerve and cervical plexus. The various branches of the external carotid artery are dissected in order to serve both as a Remmert flap and as connecting vessels. The lingual artery on the right side is removed. The cervical artery was also spared. On the left side, here too the anterior border of the sternocleidomastoid muscle is exposed and the accessorius nerve is located, protected and preserved. Exposure of the omohyoid muscle and the submandibular gland. Elevation of the gland, preserving the mandibular ramus and dissection on the digastric muscle posteriorly. Dissection along and on the internal jugular vein in a cranial direction. Here too, protect all outlets and the cervical vein. Follow the cervical vein to the hypoglossal muscle and preserve it. Now carefully dissect the lateral neck preparation and detach it while preserving the cervical plexus. It is cleared up to the omohyoid muscle, no chyle flow can be seen. There is also no increased bleeding. Now clear out the medial neck preparation, sparing all structures. The vagus nerve could also be visualized and preserved during the operation. The radial flap was then sutured into the defect. Successive suturing of the radial flap from the transcervical and transoral sides, partly after the sutures have been placed. The flap is successfully sutured in an anatomically three-dimensional manner so that both the lateral pharyngeal wall and floor of the mouth can be covered without tension, as well as the tongue and base of the tongue and the transition to the vallecula. The stalk is passed through the right side of the neck. Dissection of the facial vein, which has several outlets. Dissection of the facial artery. Anastomosis here, after conditioning the vessels with the radial artery. After opening the clamps, good arterial flow, good venous return. A branch of the facial vein is then anastomosed with the cephalic vein using a 3.5 mm coupler. The deep confluent vein is then anastomosed with another outlet from the facial vein using a 2.5 mm coupler. In each case, after opening the clamps, good venous flow and positive exclusion phenomenon. Overall, good blood flow after assessment of the flap. Extensive irrigation of the wound area. After further mobilization, the Remmert flap is sutured on the right side above the hyoid bone for volume augmentation. Subsequent careful hemostasis and irrigation of the wound area. Then wound closure in layers, with insertion of two flaps on the right and a Redon drain on the left and epithelialization of the tracheostoma. An 8 mm tracheostomy tube was then inserted and fixed in place. The defect on the forearm was primarily closed cranially and covered caudally with split skin, which was taken from the thigh on the right side. Defect augmentation using a Remmert flap from the right. Elevation of the radial forearm flap on the left by <CLINICIAN_NAME>: Palpatory identification of the distal radial artery. Marking of the flap borders 14 cm x 8 cm on the distal forearm, proximal to the flexor retinaculum, with an S-shaped incision running proximally into the cubital fossa. Incision of cutaneous and subcutaneous tissue starting proximally. Identification and visualization of the venous confluence in the cubital fossa. Identification of the cephalic vein and dissection of the vein distally with integration into the radial graft margin. Identification of the ramus externus of the radial nerve and elevation of the radial portion, leaving the peritendineum of the tendons of the brachioradialis muscle intact. Subsequent ulnar incision down to the forearm fascia. Incision of the fascia and subsequent subfascial elevation of the ulnar edge of the graft up to the tendon of the flexor carpi radialis muscle. Care is taken to leave the peritendineum on the flexor tendons and to spare the ulnar artery. Identification of the distal radial artery and trial clamping with a vascular clamp. After 5 minutes with good oxygen saturation measured by pulse oximetry (measured on the index finger), the vessels are removed with subsequent ligation (Prolene 6.0). Successive detachment of the flap pedicle from the M. pronator quadratus and M. flexor pollicis longus with ligation of the outgoing perforators using a vessel clip into the cubital fossa. Exposure and protection of the radial nerve on the medial side of the brachioradialis muscle. Exposure of the brachial artery, V. mediana cubiti, A. ulnaris. First removal of the radial artery, then of two veins of the superficial venous system. Vascular ligation by means of a bypass ligature (artery) and vascular clip (veins). Subtle hemostasis in the area of the wound bed using bipolar coagulation forceps. Two-layer wound closure in the area of the proximal forearm. Covering of the graft bed with split skin from the right thigh in the usual manner. Suturing of preparation swabs. Application of a wound dressing and a forearm splint. Completion of the graft lift without complications. Finally, attachment of the forearm. Good saturation and blood circulation of the left forearm at the end of the operation. Completion of the procedure without complications. The patient is ventilated and transferred to the intensive care unit for monitoring. Please continue postoperative antibiotics with Unacid, as started intraoperatively, for one week. Nutrition via the inserted PEG tube for approx. 10 days, followed by an X-ray broth swallow and, if necessary, diet build-up. If necessary, initiate swallowing training in the voice and speech department. Control of the flap according to the scheme for 5 days by means of clinical checks and Doppler checks. Anastomosis area marked with right cervical suture. Awaiting the final histology. Then presentation at the interdisciplinary tumor conference to indicate radiochemotherapy if necessary.