Selective tracheostomy is an effective but invasive airway management method for patients undergoing head and neck free flap reconstruction. Studies have shown that not all patients need tracheostomy. Several systems evaluating the need for tracheostomy have been proposed, but none is used clinically. A total of 533 cases underwent head and neck free flap reconstruction at Peking University School of Stomatology were reviewed for system development. Another 131 cases undergone the same surgery were included for system verification. Patients' demographic and surgical-related information were analyzed. A total of 321 cases in the development cohort and 68 cases in the system cohort underwent tracheostomy. The score was estimated: score = ∑(|log2 OR|). Patients scoring >3 required tracheostomy, those scoring <2 should avoid tracheostomy, and those scoring 2 or 3 need further evaluation. This scoring system can help determine the need for selective tracheostomy in patients undergoing head and neck free flap reconstruction. © 2019 Wiley Periodicals, Inc.