Excision of head and neck melanoma is often limited by critical structures, which can lead to incomplete excision with positive pathologic margin and increased local recurrence rate. Complete excision with recommended margins and immediate reconstruction is possible when surgical oncologists and plastic surgeons work collaboratively. Our purpose was to evaluate local recurrence rate after excision and immediate reconstruction. We reviewed 98 consecutive patients treated for primary head and neck cutaneous melanoma at a single institution between 1999 and 2004. We assessed local recurrence rate. A total of 72 patients (73%) were followed for an average of 5.2 ± 1.7 years while 26 patients were excluded due to less than 1 year of follow-up. Adjacent tissue transfer was the most common reconstruction (87%). Local recurrence was reported in 2.8% and distant metastasis in 12.5% of patients. Immediate reconstruction after excision of head and neck melanoma can be safely performed with low local recurrence rate.