OBJECTIVE Defects of the scalp and lateral temporal bone (LTB) represent a unique challenge to the reconstructive surgeon. Simple reconstructive methods such as skin grafts, locoregional flaps, or tissue expanders are often not feasible owing to a myriad of reasons. Vascularized free tissue transfer coverage offers distinct advantages in managing these defects. METHODS A retrospective case series was performed on all patients at the University of Washington Medical Center who had scalp or LTB defects reconstructed with free tissue transfer from May 1996 to July 2009. Cases were analyzed for defect characteristics, flap type, vessel selection, radiation status, dural exposure, complications, and outcomes. RESULTS A total of 68 free flap reconstructions were performed in 65 patients with scalp or LTB defects. A total of 22 resections included craniotomy, and 48 patients had preoperative or postoperative radiation. Defects ranged from 6 to 836 cm(2). All flaps (46 latissimus, 11 rectus, 4 radial forearm, 6 anterolateral thigh, and 1 omental) were transferred successfully. Vein grafts were required in 5 cases. Complications included delayed flap failure requiring secondary reconstruction, neck hematoma, venous thrombosis, skull base infection, large wound dehiscence, small wound dehiscence, donor site hematoma and seroma, and cerebrospinal fluid leak. Cosmetic results were consistent and durable. CONCLUSIONS Microvascular free tissue transfer is a safe and reliable method of reconstructing scalp and LTB defects while offering favorable cosmetic results. We favor the use of latissimus muscle-only flap with skin graft coverage for large scalp defects and rectus or anterolateral thigh free flaps for lateral temporal bone defects.