Purpose <p>Almost half of all head and neck cancer patients in an Indian subcontinent are aged 60 years and above. This geriatric cohort faces its own unique challenges during perioperative period. This study aims at identifying the risk factors for surgical complications in geriatric head and neck cancer patients in an Indian subcontinent.</p> Methods <p>A retrospective analysis of all geriatric head and neck cancer patients operated at a National Cancer Institute from January 2020 to December 2023 was done. 168 patients were screened for their demographic profile, clinicopathological and surgical details, and their impact on the surgical outcomes was analyzed.</p> Results <p>Our results indicate that female sex, an advanced T stage (T4a, T4b), regional flap usage for reconstruction, and having a higher ACE-27 category are all associated with increased odds of Clavien-Dindo3A/3B surgical complications. Conversely, having an ACE-27 category less than 1 suggests a trend towards lower odds, although it did not observe any statistical significance.</p> Conclusion <p>Our study strongly advocates risk stratification in geriatric cohort with head neck squamous cell carcinoma (HNSCC) to optimise surgical outcomes and reduce perioperative morbidity and mortality. ACE-27 is useful tool to objectively predict patients at risk for perioperative morbidity.</p> Level of Evidence <p>Level 4.</p>