Reconstruction of the scalp after acquired defects remains a common challenge for the reconstructive surgeon, especially in light of a history of radiation to the area. Wound healing by secondary intention or with a wound vacuum assisted closure are viable options provided certain criteria are met. With the former, secondary intention works best when the pericranial layer is present on a concave surface in patients with fairer skin tones. The addition of growth therapy factors should be used cautiously in patients with a known neoplasm. In terms of surgical interventions primary closure in defects smaller than 3 cm or more if not on a tight region of the scalp offers the simplest reconstructive option. Split skin grafting is a viable option for medium to large scalp defects. An available nutrient blood supply via the pericranium is the preferred bedding recipient. However, in cases of a bare calvarium a large pericranial bipedicled flap, drilling the outer cortex to expose the diplopic space, or packing the wound to aid the formation of granulation tissue aim to overcome this problem. Meanwhile, local flaps are safe and have low complication rates. Regional flaps are less popular in the era of free tissue transfer but may be an option in patients with impaired wound healing who need large amounts of vascularised tissue. Free tissue transfers, especially from the lattisimus dorsi, provide excellent options for reconstructing the large or total scalp defects. The superficial temporal artery and veins provide convenient and adequately sized recipient vessels for anastomosis. The novel algorithm the article creates provides a comprehensive view on how to approach scalp defects using approaches previously described in the literature, including factors such as scalp defect size, defect location, radiation history and hairline distortion.