Repair of scalp defects is often challenging, because without careful planning, excision of the defect may leave unsatisfactory cosmesis. Contemporary techniques in hair restoration surgery allow creation of natural and undetectable results, but these techniques are often unsuitable for repairing large scarred areas of hair loss. However, by using older techniques of scalp reduction and tissue expansion, excision of many large scarring defects can be accomplished. Combining older methods with modern hair restoration surgery permits the satisfactory treatment of many previously untreatable conditions. This article focuses on tissue expansion as an adjunct to repairing large scalp defects.