First, another oral cavity inspection and pharyngoscopy. The deeply ulcerated tumor on the left edge of the tongue is seen, which extends into the base of the tongue and runs towards the floor of the mouth and the lingual box. First transoral tumor resection: insertion of a retractor, placement of a tongue tie suture. Tumor is removed on all sides with a safety margin of 1.5 to 2 cm. The posterior 2/3 of the tongue including the base of the tongue, floor of the mouth including the lingual nerve and parts of the submandibular and sublingual glands as well as the tonsil and glossotonsillar junction are removed. The specimen is marked with a thread and sent for frozen section. No infiltrates in all margins in the frozen section, thus R0 situation. The lingual artery was ligated during the transoral resection. Careful hemostasis. Repositioning for neck dissection and tracheostomy. First radical neck dissection on the right: skin incision in typical manner. Exposure of the sternocleidomastoid and omohyoid muscles as well as the digastric muscle. Exposure of the internal jugular vein, external carotid artery. Large vessels can be dissected cranially from the lymph node conglomerate. Vagus nerve is exposed and preserved. Also the hypoglossal nerve. N. accessorius cannot be preserved and is resected together with the sternocleidomastoid muscle. Similarly, hardly any muscular structures can be preserved in the cranial part. The metastasis is infiltrated in muscular structures and in the cervical plexus. All branches infiltrated by the lymph node conglomerate are also resected, including the accessorius nerve. All deep cervical muscles and neck muscles are also resected, including the trapezius muscle. Caudally positive lymph nodes up to level V. Branches of the cervical plexus can be preserved in the caudal part. Evacuation level II to V. Due to the extensive lymph node metastasis, large areas of subcutaneous tissue below the nuchal and occipital skin as well as muscular tissue are removed. This is sent for frozen section. No more tumor infiltrates here. The submandibular gland is removed to create an enoral tunnel. The digastric and styloid muscles are severed. Remains of the lingual nerve are removed together with the gland. The lingual nerve had already fallen during the transoral tumor resection. The hypoglossal nerve can be preserved. Subsequent neck dissection on the left side: exposure of the sternocleidomastoid, omohyoid and digastric muscles. Exposure and preservation of the internal jugular vein, internal carotid artery, external carotid artery. Visualization of the superior thyroid artery and hypoglossal nerve, accessorius nerve and vagus nerve. Also visualization of the border cord. Evacuation level II to IV, followed by tracheostoma placement. Kocher's collar incision. Exposure of linea alba. Dissection of the infrahyoid musculature, visualization of the thyroid isthmus. This is passed underneath, clamped off, severed and supplied by means of puncture ligatures. Subsequent exposure of the trachea. In the 2nd/3rd intercartilaginous space, enter the trachea and create a wide pedicled modified Björk flap. This is epithelized in the typical manner. Re-intubation and creation of a Woodbridge tube. Subsequent removal of the forearm graft from the left: After measuring the size, which is 10-11 x 6-7 cm, the flap is marked in the corresponding orientation for the course of the pedicle. The flap is then lifted from the ulnar subfascial side, followed by an incision in the crook of the elbow. Expose the superficial venous system and connect to the deep venous system. Then expose the flap radially and lift subfascially. The lateral cutaneous ramus of the antibrachial cutaneous nerve is exposed and preserved. Distal exposure of the radial artery and accompanying veins. Initially clamp for a few minutes. Exposure of the pedicle along the brachioradialis muscle. Exposure and connection of the deep superficial venous system. A cephalic vein with 2 outlets can be visualized in the crook of the elbow. The radial artery and a relatively well preserved confluence can also be visualized. Then dissection of the radial artery distally. Saturation always at 100 %. Successive elevation of the flap subfascially. Smaller vessels are supplied bipolar or with clips. Lift up to the crook of the elbow. Exposure of the radial artery and venous outlets. Deposition of the flap on 2 outlets from the cephalic vein, which are ligated, as well as deposition on an outlet corresponding to the confluence and ligation here. The radial artery is removed, which is treated with a 6-0 Vascufil suture. The interosseous artery is also severed. Treatment with clips. After previous clamping, the hand was also always well perfused with saturation of 99-100%. The flap is then removed and flushed with heparin solution. A piece of split skin 0.8 mm thick is removed from the thigh. This is then treated with a hydrogel dressing. Split skin is worked into the defect. Complete defect coverage. Closure primarily cranially. Insertion of a Redon drain underneath. Subsequent hydrogel-Mepilex dressing. Cover with a cotton swab dressing. Wrapping in absorbent cotton. Fitting of a Cramer splint. This is fixed in a functional position with a tape bandage. Hand still with normal saturation when attached. Now suture the flap: After sutures have been placed, the flap is successively worked into the defect. The pedicle is passed caudally in between. The flap can be worked into the defect without tension. Complete functional closure of the defect. Subsequent anastomosis of the flap. Conditioning of the superior thyroid artery and the radial artery. Anastomosis with 9.0 Ethilon single-button sutures. After opening the clamp, good arterial flow and good venous return. The facial vein is then exposed with 2 outlets and conditioned. After conditioning, the larger outlet is anastomosed with the confluence with 3-0 coupler. After opening the clamps, good venous flow smear, positive phenomenon. Subsequently, before the outlets of the cephalic vein, the larger one is anastomosed with the second outlet from the facial vein, also with a 3-0 coupler. Again, good venous flow after opening the clamp. Positive smear phenomenon. The other outlet is closed or ligated. Subsequent careful hemostasis. Irrigation of the entire wound area. Wound closure on the left with insertion of 2 flaps. Wound closure on the right after careful hemostasis and irrigation with insertion of a Redon drain. Insertion of an 8-0 tracheostomy tube. Completion of the procedure without complications. Patient admitted to intensive care unit for postoperative monitoring. Please continue the intraoperative antibiotic treatment with Unacid for one week. Nutrition via the inserted PEG tube for 7-10 days. Then, if necessary, swallow gruel and build up diet. Please continue intraoperative therapy with heparin perfusor 500 E/hour for 5 days. Flap control clinically according to the scheme for 5 days. Overall cT2-3 squamous cell carcinoma of the tongue margin/base of tongue and glossotonsillar junction. Extensive lymph node infiltration in the soft tissue nuchal occipital right. Therefore radical neck dissection. Postoperative RCT certainly indicated. Presentation in the interdisciplinary tumor conference.