Aplasia cutis congenita (ACC) is rare condition characterized by the congenital absence of skin. ACC is most commonly seen over the vertex of the scalp. Lesions of the head can present as full thickness defects involving scalp, calvarium, and dura. These composite defects of the scalp represent a reconstructive challenge due to the paucity of skin for coverage of vital structures. The two most widely reported complications are exsanguinating hemorrhage and meningitis. Numerous conservative and operative therapies have been reported, however the treatment of ACC remains controversial. The larger composite defects require earlier operative intervention to avoid complications. We present two cases that review the management of large composite ACC defects in neonates. We propose that when dealing with large scalp defects, early aggressive surgical management using multiple scalp rotation flaps is the intervention of choice. This method can prevent the development of complications, provide a satisfactory functional and cosmetic outcome, reduce hospital stays, and provide cost effective care by reduction of time to wound closure.