PURPOSE. Wide local excision (WLE) of head and neck melanoma (HNM) is limited by proximity to critical structures. Incomplete excision contributes to high recurrence rates. Therefore, reconstruction is often delayed until confirming margins. Immediate adjacent tissue transfer may promote complete excision, reduced local recurrence, and improved aesthetics. Our purpose is to determine the incidence, patient, and tumor characteristics associated with a positive margin; and establish criteria for performing immediate reconstruction. METHODS. We retrospectively reviewed 117 consecutive patients after WLE of HNM and reconstruction. We evaluated patient and tumor characteristics, reconstruction timing, and margin status. We performed univariate and multivariate regression analyses. RESULTS. Reconstruction was immediate for 107 and delayed for 10 patients. Six percent had a positive margin. No difference in positive margin incidence was found between immediate and delayed reconstruction (P=0.11). Positive margin independent predictors were locally recurrent (OR,62.7[95%CI,7.4-532.7],P<0.001) and T4 tumors (OR,8.02[95%CI,1.02-62.71],P=0.04). CONCLUSIONS. Immediate reconstruction depends on knowledge of characteristics associated with histologically positive margins. We found a low positive margin incidence and identify locally recurrent and T4 tumors as independent predictors of a positive margin. Immediate reconstruction is safe and may promote complete excision. Delayed reconstruction should be considered for locally recurrent or T4 tumors.