BACKGROUND Acral lentiginous melanoma (ALM) is a biologically distinct, inherently aggressive, and understudied melanoma subtype without a unified surgical approach. OBJECTIVE To provide an updated review of ALM and offer practical, surgeon-focused guidance on diagnosis, biopsy, margin-controlled excision, and Mohs micrographic surgery (MMS)-based management of ALM. METHODS & MATERIALS A PubMed/MEDLINE search of ALM, with an emphasis on articles published after 2015. RESULTS ALM demonstrates inherent biological aggressiveness characterized by extensive subclinical spread, delayed diagnosis, and higher stage-adjusted recurrence compared with nonacral cutaneous melanomas. Anatomic constraints additionally necessitate specialized surgical approaches, although current management is extrapolated from nonacral melanoma data. Retrospective data support MMS and margin-controlled excision and tissue preservation in ALM, with the benefit of digit-sparing surgery and functional preservation. No randomized trials have included ALM, highlighting a key evidence gap. CONCLUSION Margin-controlled approaches such as MMS may improve local control and tissue preservation in select ALM patients. Prospective ALM-specific research and standardized diagnostic and surgical protocols are strongly needed.