Merkel cell carcinoma (MCC) is a rare, aggressive skin cancer with a recurrence risk of ~40%; however, prognosis for low-risk, stage I disease is excellent with primary surgical management. The role of post-operative radiation therapy (PORT) is controversial as it can cause significant and acute long-term side effects. Here, we assess the efficacy of PORT on local recurrence (LR) rates in patients with pathological stage I MCC with primary tumors on the head/neck (HN) vs. non-head and neck (Non-HN) sites. One hundred forty-seven MCC patients treated from 2006-2020 were identified from an IRB-approved prospective registry who had ‘low-risk’ disease: pathological T1 primary tumor resected with negative margins, negative pathologic node status, and no immunosuppression. LR was defined as tumor recurrence within 2 cm of the primary surgical bed. I led compilation of the cohort, and contributed to discussion of results, and development of the figures and manuscript. Seventy-nine patients received PORT (30 HN, 49 Non-HN), and 68 patients were treated with surgery alone (30 HN, 38 Non-HN). Addition of PORT was associated with a decreased risk of LR across the entire cohort (5-year rate: 9.5% vs. 0%, p=0.004), with 6 LRs in the surgery alone group. The addition of PORT significantly reduced LR rates among HN patients (21% vs. 0%, p=0.034). Conversely, no LRs were observed in Non-HN patients. No significant MCC-specific survival differences were observed. For low-risk MCC of the extremities and trunk, excellent outcomes were achieved with surgery alone. However, HN MCC was a risk factor for LR that was significantly reduced with PORT. Overall, this study demonstrates the importance of primary tumor site location for prognosis and treatment of MCC to determine patients that would benefit from PORT and those that can be spared the toxic side effects of radiotherapy.