Background: Australia faces the highest global incidence of melanoma, emphasizing the importance of accurate staging and effective management strategies. Sentinel lymph node biopsy (SLNB) is integral in assessing melanoma metastasis, with lymphatic drainage patterns guiding surgical interventions. We present a case of lentigo maligna melanoma (LMM) on the nasal sidewall with unexpected retropharyngeal lymph node drainage, challenging conventional mapping techniques. Case: An 83-year-old male underwent wide local excision for a T3b LMM, with preoperative lymphoscintigraphy revealing retropharyngeal drainage bilaterally. Traditional SLNB was precluded due to morbidity concerns. Surgical resection and reconstruction ensued, yielding a clear pathological margin. Subsequent staging showed no locoregional or metastatic disease. Discussion: Head and neck melanomas exhibit varied lymphatic drainage patterns, influenced by intricate regional anatomy and age-related changes. While lymphoscintigraphy is a reliable technique, discordant drainage can occur, potentially due to embryological remnants or mapping inaccuracies. Literature review reveals no prior cases of nasal melanomas draining to retropharyngeal nodes. Conclusion: This case underscores the necessity of understanding anatomical variations in melanoma drainage. Further research is warranted to refine lymphatic mapping techniques and elucidate the peculiar drainage pathways observed in nasal melanomas. As systemic therapies revolutionize melanoma treatment, accurate staging becomes increasingly pivotal, urging a comprehensive exploration of lymphatic drainage patterns to enhance diagnostic precision and guide therapeutic decisions in head and neck melanoma.