The reconstruction of any body region represents a unique surgical challenge, which must take into account the anatomy of the affected tissue, the extent of the defect, the cosmetic and functional result intended and the likelihood and speed of a return to activities of daily living. The normal scalp is a laminated, thin structure made of tissues containing collagen, elastin, hair follicles, neurovascular structures, connective tissue and sebaceous and sweat glands. We review a retrospective series of 30 patients with large scalp defects, involving soft tissue and pericranium after resections of skin malignancies. In all cases, microvascular tissue transfers was used for reconstruction, providing primary wound healing. The preferred flap was the latissimus dorsi muscle, which atrophies significantly over time, and can be suitably contoured when placed over the skull. In all cases, the surface area scalp defect ranged berween 30 and 100% of the total scalp. Complications were limited to recurrences and small wound breakdown. Five patients died from the original disease. All others were found to be disease free at follow up, which averaged close to 12 years. When used for reconstruction of large scalp defects, the latissiums dorsi free muscle flap demonstrates excellent durability and cosmetic result, reliable wound healing and is a well tolerated donor site in all patients.