More than 100,000 cases of cutaneous melanoma will be diagnosed this year in the United States, and the incidence continues to rise worldwide. Although melanoma represents only 1% of all skin cancers, it is responsible for the majority of skin cancer deaths. Major risk factors include age, UV-light exposure, and fair skin. Surgery remains the first-line treatment for primary cutaneous melanoma with the goal of achieving histopathological clearance to reduce the risk of recurrence. Cutaneous melanoma of the head and neck (CMHN) represents about 20% of all melanoma cases and poses a unique set of challenges, given the need to balance adequate oncologic resection with significant functional and cosmetic concerns. CMHN is also more likely to present with a deeper Breslow thickness and is associated with a higher likelihood of positive margins, higher recurrence rate, and worse survival than melanoma of the trunk and extremities. Histopathological subtypes in the head and neck also differ from melanoma of the trunk, with a much higher proportion of lentigo maligna (LM) and LM melanoma subtypes, which can often have significant subclinical spread beyond the pigmented lesion. Despite these differences, current National Comprehensive Cancer Network (NCCN) guidelines for the recommended excisional margins of cutaneous melanoma are based on randomized controlled trials that mostly excluded tumors of the head and neck. Therefore, the recommended margins for CHNM remain highly controversial. While there is a paucity of controlled, prospective studies assessing wide local excision (WLE) margins in CMHN, several large retrospective studies have suggested that narrow margins lead to high rates of recurrence but also that excessively wide margins do not confer an oncologic benefit. Utilizing the Surveillance, Epidemiology, and End Results database, a large population-based study with over 3,500 cases compared narrow resection margins (1–2 cm) to wide margins (>2 cm) in CMHN and found that margins >2 cm did not confer an additional benefit in overall or melanoma-specific survival (MSS). Importantly, this study found that the use of wider margins did not result in a survival benefit in patients with more advanced disease, anatomic location, or sentinel lymph node spread. Furthermore, regardless of T-stage, patients with >2 cm surgical margins had similar disease-specific survival to patients who had 1–2 cm margins.1 As expected, patients with excessively narrow clinical margins <1 cm have poorer oncologic outcomes. In 372 patients with T2 cutaneous melanoma, one retrospective study found that those who had a pathologic margin of <0.8 cm (equivalent to <1 cm clinical margin) had worse MSS compared to the 0.8–1.6 cm group (equivalent to 1–2 cm clinical margin).2 There were no differences in disease-free survival and local recurrence between the two groups. In contrast, another single-center study on T4 CMHN found a high rate of locoregional recurrence (27%), but margins ≥2 cm failed to offer any benefit in recurrence rates or MSS.3 Alternative techniques to WLE such as Mohs micrographic surgery (MMS) and staged excision (SE) have gained acceptance due to their reliance on histopathologic rather than clinical margins. MMS and SE allows for comprehensive margin assessment which can be utilized for tumors with clinically ill-defined margins in sensitive locations such as the lip and peri-ocular area. While there are no randomized trials comparing MMS or SE with standard WLE, observational studies have shown comparable or improved local recurrence rates in early-stage disease. Furthermore, no randomized, controlled studies have demonstrated that MMS and SE ultimately have narrower clinical margins compared to WLE. In a large single-institution cohort of over 1,300 patients undergoing MMS with LM and melanoma in situ (MIS) lesions of the head and neck, a 0.6 cm margin cleared 79% of LM and 77% of MIS while a 1.2 cm margin resulted in 97% clearance rate for both.4 The 5- and 10-year local recurrence rates were less than 0.4% for both types of lesions. The authors performed a systematic review of 19 studies with 3883 patients and found that the mean margin of 1.9 cm was required to obtain a 97% clearance rate for MIS of the head and neck. The largest case series of SE for CMHN also offers similar insights. In Moyer et al., 564 MIS lesions and 270 invasive melanomas underwent “square” SEs.5 The mean margin for histologic clearance was 0.93 cm for MIS and 1.37 cm for invasive melanoma. The estimated local recurrence rates were 1.4% at 5 years and 2.2% at 10 years. In conclusion, due to the functional and cosmetic importance of the head and neck, guidelines for melanoma resection and appropriate margins should be developed separate from lesions of the trunk and extremities. However, the current literature assessing the role of margins in CMHN has significant limitations including a high risk of bias in patient and treatment selection, high heterogeneity in the measured outcomes, and a limited number of prospective studies. Current NCCN margin guidelines for WLE based on T-stage are appropriate for melanoma of the head and neck. The studies presented suggest that 1–2 cm margins for WLE are appropriate for all T-stages and that extending beyond 2 cm does not offer a survival benefit. Observational studies for MMS and SE demonstrate similarly low 5-and 10-year recurrence rates in MIS and T1 invasive melanoma, but lack evidence that they have narrower margins or are more tissue sparing compared to WLE. Future studies should prospectively investigate whether margins based upon T-stage can be reduced further without compromising disease recurrence.