Following ablation of head and neck cancers there are many options of reconstruction, depending on many factors, such as age, defect size and location, tissue components required for reconstruction, general health of the patients and special medical problems, job, socio-economic condition and motivation of the patients, experience of the surgeons and facilities of the hospital, etc. Regardless of many advantages of the keystone flap as described by the authors, this flap has the following limitations which the plastic surgeons should take into consideration before deciding to use this flap 1 Coskunfirat O.K. Chen H.C. Spanio S. et al. The safety of microvascular free tissue transfer in the elderly patients. Plast Reconstr Surg. 2005; 115: 771-775 Crossref PubMed Scopus (115) Google Scholar , 2 Kimata Y. Uchiama K. Ebihara S. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg. 1997; 123: 1325-1331 Crossref PubMed Scopus (174) Google Scholar , 3 Huang W.C. Chen H.C. Wei F.C. et al. Chimeric flap in clinical use. Clin Plast Surg. 2003; 30: 457-467 Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar , 4 Chen H.C. Tang Y.B. Anterolateral thigh flap: an ideal soft tissue flap. Clin Plast Surg. 2003; 30: 383-401 Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar : (1)location and size of the defect: Its size is not enough for reconstruction of very large defects. When its width or length cannot meet the requirement of the wound, the tension in wound closure would cause problems. In case the distal portion of the keystone flap develop necrosis, adding another flap would make the face look ugly. When tumor excision is conservative, the chance of local recurrence would increase due to inadequate safety margin. Other complications may occur if the flap will pull on the eyelid or oral commissure due to inadequate length of the keystone flap. This flap cannot be used in the advanced cases with extensive defects, or defect of the palate. It is thin and is not a good flap to cover the reconstruction plate which is used to replace the mandible. The plate may be exposed more easily than other flaps with thick dermis and muscle. (2)Its arc of rotation is limited, not like a free flap. (3)Tissue components required for reconstruction: The keystone island flap only provides skin which can be used for outer lining in most situations. It does not contain osseous components for bone reconstruction. (4)Most old patients may have loose skin, but if they have previous radiation therapy the skin can be indurated and less flexible. Therefore the transposition of the flap may become more difficult. (5)It is important to make sure that the blood supply of the keystone flap has not been disrupted by either surgical ablation of cancer or by radiation therapy. (6)In certain areas of the neck, if the flap is replaced by skin graft the neck movement can be limited.