Purpose: Calvarium exposure is a recognised complication in surgical and radiotherapeutic treatment of scalp malignancies, leading to bone desiccation, infection, and sequestration. These complications pose significant risks to patient morbidity and mortality and require resource-intensive management. However, its incidence across treatment modalities remains poorly defined. A clearer understanding could improve pretreatment counselling, guide clinical decisions, and optimize resource allocation. Method: Medical records of 1037 patients presenting with head and neck lesions at our center between 2016-2022 were retrospectively reviewed. T2 or T3 scalp malignancies on hair-bearing areas were included. Data on demographics, lesion characteristics, comorbidities, and complications were analysed. Results: 145 patients were included. Calvarial exposure was most frequent in dual-therapy patients (7.69%), followed by radiotherapy-only (6.06%) and surgery-only (3.95%). Radiotherapy patients had significantly higher Charlson Comorbidity Index (CCI) scores than surgical patients (+0.97, P<0.05). Within the radiotherapy group, patients with calvarial exposure received an average of 23.03 Gy more than those without (P=0.0011). In the surgical cohort, exposure occurred exclusively in patients treated with skin grafts, alone or with transposition flaps. Healing was achieved only through surgical intervention; conservative management with dressings was ineffective. Conclusion: Dual therapy carries the highest risk of calvarial exposure. Although overall incidence remains low, outcomes are poor. Identified risk factors include larger skin resections, higher radiotherapy doses, and elevated CCI scores.