INTRODUCTION: The proximity of head and neck melanomas to critical anatomical structures requires that surgeons achieve a balance between adequate margins of excision and the functional and cosmetic needs of patients. Although the current National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines state that wide local excision margins may be modified to accommodate individual anatomical considerations, no evidence evaluating the safety of this practice exist. This study sought to determine the risk associated with reducing margins of wide local excision in head and neck melanoma. Secondarily, patient satisfaction following reconstruction of resultant detects was evaluated. METHODS: Sixty-nine cases of head and neck melanoma were treated by wide local excision and followed prospectively for local recurrence. Forty wide local excisions were performed according to current practice guidelines (0.5cm for in situ lesions, 1cm for lesions <1.0 mm thick, 1-2 cm for lesions 1.01-2.0 mm thick, and 2 cm for lesions >2.01 mm thick). Reduced margins (0.5 cm for lesion >1.0mm thick, 1.0 cm for lesion > 1.01 mm thick) were utilized in 29 cases to preserve critical anatomical structures such as the eyelid, nose, mouth and auricle. Method of reconstruction was documented in each case, and a visual analog scale was utilized to assess patient satisfaction with the reconstructive outcome. RESULTS: Overall local recurrence rate was 8.7% over a mean follow-up period of 28.6 months. Reducing margins of wide local excision did not increase local recurrence rates as demonstrated by local recurrence-free survival (89.7% vs. 83.5%, p=0.653). Patients with reduced margins were more likely to be closed primarily or with local flaps than patients with recommended margins (p=1.84)and their reported satisfaction scores were concomitantly higher (p=0.046). CONCLUSION: This study suggests that margins of wide local excision may be safely reduced in melanomas in close proximity to structures of the head and neck without without increasing recurrence rates and preserving patient satisfaction.