Induction of anesthesia and intubation by the anesthetist, then sterile washing and draping. Insertion of a covered retractor. Snare the tongue, then inspect the tumor region. The tumor extends from the base of the tongue to the tonsil region to the anterior and posterior palatal arch and passes over to the soft palate and extends to the base of the uvula, but does not infiltrate it. First transoral tumor resection using a monopolar needle, scissors and bipolar forceps so that the tumor is detached from the soft palate and the tonsil region as well as from the tongue margin. Then switch to the transcervical approach. To do this, make a skin incision in a transverse skin fold 2 ˝ cm below the lower jaw. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Showing the submandibular gland. Exposure of the cervical vascular sheath. First resection of the submandibular gland. The lower part of the tumor is then immediately encountered. A pharyngotomy is performed here, then the tumor is dislocated transcervically and successively cut around. It can be removed en bloc. The entire tumor is then thread-marked and sent for frozen section. In the frozen section, all edges are tumor-free. Basally in the area of the tongue, the margins are only very narrowly resected. Therefore, a resection is made here again, which is sent for final histology. Now complete the neck dissection. For this, free preparation of the internal jugular vein. Exposure of the N. accessorius, the V. facialis, which must be removed, the A. thyroidea superior and removal of the neck IIa to Va while sparing the plexus branches. Measurement of the defect reveals a fairly large defect in the area of the edge of the tongue and the oropharynx. The flap is then configured so that one part can cover the posterior pharyngeal wall and one part goes to the tongue with a notch so that the tongue is not fixed later. This graft is drawn onto the forearm. Then cut around the skin. Exposure of the brachioradialis muscle. Exposure of the cephalic vein, exposure of the deep venous system in the crook of the elbow. The patient has no direct confluence in the crook of the elbow between the superficial and deep systems. The cephalic vein is therefore directly integrated with the graft. Exposure of the superficial ramus, radial nerve, this divides into 2 branches, unfortunately one branch cannot be preserved, but the larger main branch remains. Then visualization of the radial artery, clamping, ligation and repositioning of the radial artery. Detach the graft from the tendon bed, then dissect the pedicle in the usual way. Smaller vessels are clipped and bipolar coagulated. Then dissection of the vessel outlet in the elbow area. Exposure and identification of the ulnar and interosseous arteries. The radial artery is removed distally from its outlet. The cephalic vein and a larger accompanying vessel of the radial artery are dissected for the venous connection. The arm is then closed in the usual way using split skin. Neck dissection on the left side and tracheotomy by <CLINICIAN_NAME> are now performed in parallel with graft elevation. Now proceed to the tracheotomy: First mark the landmarks (jugulum, cricoid cartilage, thyroid incisura). Mark the skin incision. This is located at mid-height between the jugulum and the cricoid cartilage. Skin incision at a length of approx. 4 cm. Dissection through the subcutaneous tissue. Two larger veins must be ligated and cut. Then dissect the linea alba of the infrahyoid musculature. Spread the muscles apart. Finding the thyroid isthmus. This is now dissected along the trachea. Then insertion of the Pean clamps and transection of the isthmus after bipolar coagulation. Ligation of the left and right isthmus. Free preparation of the trachea. Entering the trachea after preoxygenation between the 2nd and 3rd tracheal cartilage. Formation of a Björk flap and tracheocutaneous anastomosis in the typical manner. Retubing of the patient to a 9-gauge cannula. Proceed to neck dissection on the left side. The incision is first made at a length of approx. 7 to 8 cm, approx. 2 transverse fingers below the mandible in a skin fold. Dissection through the subcutaneous tissue. Exposure and separation of the platysma and formation of a platysmal flap. This is exposed cranially and caudally. The anterior edge of the sternocleidomastoid muscle is then dissected caudally to the omohyoid muscle, which is then dissected cranially/medially. Further dissection of the anterior edge of the sternocleidomastoid muscle. Locate the submandibular gland. Dissection of the caudal glandular capsule and insertion into the anterior neck preparation. Locate the digaster venter muscle posteriorly and move along it anteriorly as far as the hyoid. Release the anterior neck preparation while protecting the hypoglossal nerve, which can be visualized and protected. Now dissect the cervical vascular sheath. The internal jugular vein and facial vein are exposed and spared. The common carotid artery and external carotid artery are exposed and spared, as are the vagus nerve and the cervical artery. The accessorius nerve is then explored. Dissection of level II b. Detachment of the fatty tissue with the lymph nodes along the sternocleidomastoid muscle and the internal jugular vein to level IV caudally, level V is also removed. The fatty tissue is ligated and removed caudally in level IV. Detachment of the lateral neck preparation. Subsequent insertion of an 8 Redon drain. Subcutaneous suture with 3.0 Vicryl and skin suture with 4.0 Ethilon. Now insertion of the graft, first transcervically, then transorally. This is relatively difficult as the uvula, tongue and the entire oral mucosa are very swollen. In the end, the graft can be inserted completely. The vessels for the anastomosis are now exposed. For this purpose, the superior thyroid artery and the facial vein as well as an outlet from the internal jugular vein are taken. Finally, an artery and two veins are connected, which is successful without any problems and ensures good perfusion in the graft area. Insertion of a flap and two-layer wound closure. Re-intubation to a 9 mm tracheostomy tube. The patient is ventilated and admitted to the intensive care unit. Please X-ray pre-swallow on the 10th postoperative day, until then nutrition via the previously inserted PEG tube. The PEG tube was inserted with good diaphanoscopy using the thread pull-through method.