The reconstruction of defects that involve the scalp and forehead presents unique aesthetic and functional challenges. This article reviews the surgical anatomy of these regions and presents an algorithm for decision making in reconstructive surgery. Nonmicrosurgical techniques are briefly reviewed. The microsurgical reconstruction of scalp and forehead defects differs from the more common oropharyngeal reconstructions in several ways, including flap choices, choices for recipient vessels, and the opportunity to use conventional and microsurgical techniques simultaneously to improve outcomes. Each of these considerations is reviewed and the authors' preferred techniques presented.