Tracheostomy is an accepted surgical procedure that is one of the oldest ways of securing the airway. It is widely accepted to protect the airway after big cases of head and neck cancer and especially following free flap reconstruction. It can, however, be associated with several complications including death, these rates have been quoted as high as 8-45%. These include local ones such as bleeding, displacement, obstruction, surgical emphysema or chest complications, e.g. pneumothorax, local inflammation or infection and long-term ones such as fistulae and failure to be able to decannulate. There are now many studies that confirm the increased length of stay and complications of patients with these temporary tracheostomies. This is a retrospective study from a single centre in Germany of 150 patients with head and neck cancer that were treated between March 2017 to August 2018. All patients had a resection, single or bilateral neck dissection and free flap reconstruction. They also include patients with osteoradionecrosis with microvascular reconstruction (26 patients, i.e. 17.3%) Male to female ratio was 1.8:1 and the median age was 63.8. The commonest free flap used was the radial forearm. Post-surgery all patients spent the first night sedated and a further 10.8% stayed a further night. Eighteen patients required ITU admission for pneumonia, delirium, pulmonary embolism, sepsis and cardiac failure. The length of stay varied between five to 66 days with a median stay of 18.11 days. Most patients were decannulated successfully within a range of two to 56 days, the longest was a patient with pneumonia and respiratory failure. In seven cases the cannula had to be reintroduced due to infection / pneumonia. Length of hospital stay ranged from eight to 72 days with a mean of 19.83, as expected patients that had a complication of the tracheostomy stayed longest. Their complication rate is stated as 30%, the commonest one was pneumonia, a risk factor for this were age, pre-existing COPD, alcohol abuse, ASA-3 and length of cannulation of tracheostomy. Two patients needed a further operation due to bleeding from the tracheostomy site. They specify the use of anticoagulation and Aspirin as risk factors for this. This is a retrospective study, it is a single unit but very insightful nonetheless. A very good review of the complications is given. Unfortunately, in spite of the risks, a temporary tracheostomy is still the safest surgical airway following major ablative head and neck and reconstructive surgery.