Introduction <p>Tracheostomy is commonly used to secure the airway during the immediate postoperative period in complex maxillofacial surgery due to significant post operative edema leading to narrowing of airway. This study reviews 10 years of experience with elective tracheostomy in head and neck surgeries in a single tertiary centre. The primary objective of the study was to review the need of elective tracheostomy its advantages, disadvantages and incidence of intraoperative, perioperative and postoperative complications in head and neck surgeries.</p> Materials and methods <p>Retrospective tertiary centre study conducted in the Department of Oral and Maxillofacial surgery between 2014 to 2024. The study included 250 out of 262 patients in all age groups and either sex, who underwent elective or emergency tracheostomy for complex head and neck surgeries with microvascular free flap transfers.</p> Results <p>The study showed a male predilection with mean tracheostomy time of 20 minutes and operative time of 11 hours. The patients had an ICU stay of 4 days and elective ventilation of one day with mild tracheal secretion seen postoperatively. No other complications were noted intraoperatively or perioperatively. 5(2%) out of 250 patients developed postoperative chest infection (pneumonia) and were managed conservatively.</p> Conclusion <p>Elective tracheostomy even though an invasive tool when used properly in selected patients, can be safe and beneficial in microvascular free flap surgeries. Comprehensive care including routine monitoring, tracheostomy care, suctioning the airway, humidification, nebulization, monitoring for complication, nutrition and hydration of the patient is required.</p>