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) 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.
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