We present an interesting and novel technique to reconstruct the tragus of the ear after oncological resection, using a pedicled chondrocutaneous superficial temporal artery perforator (STAP) flap. A 77-year old lady was referred to our clinic after shave biopsy of a squamous cell carcinoma of the right tragus. We advised a wider excision and reconstruction, utilizing like-for-like tissue of the helical root on the same ear. Intraoperatively, wider excision of the squamous cell carcinoma was performed with a 6-mm resection margin and the posterior branch of the superficial temporal artery (STA) carefully preserved. Corresponding chondrocutaneous tissue of the helical root was remarked ([Fig. 1a] [b]). Using the microscope and hand-held Doppler, the perforating artery of the posterior branch of STA and its single corresponding venae-comitantes running into the helical root tissue was identified and preserved, and the helical root tissue was incised. Superiorly, the posterior branch STA artery and vein were ligated using microligation clips ([Fig. 2a] [b]). The chondrocutaneous flap was transposed on the deep temporal fascia from superior to inferior and into the tragal defect ([Fig. 3a] [b]). The donor site was closed directly, the flap was easily inset into the oncological resection defect, and simple interrupted sutures were used for skin closure. Free chondrocutaneous STAP flaps have been well described[1] [2] for nasal alar reconstruction, utilizing the posterior branch of the STA. However, the use of a pedicled chondrocutaneous STAP flap for reconstruction of auricular defects has not previously been described and represents an excellent reconstructive option for defects around the ear. Scaglioni[3] eloquently demonstrates a posterior perforator of the STA to the root of the helix in a cadaveric study, using latex and barium sulfate injection from the external carotid artery and the use of this angiosome to reconstruct anterior ear skin defects with a tunneled pedicled flap. We have developed this angiosome further by using the same perforator to elevate a chondrocutaneous flap of the root of the helix in order to reconstruct the tragus. To the best of our knowledge, this is the first time a pedicled chondrocutaneous flap has been described using this angiosome. Chondrocutaneous tissue at the root of the helix offers the best aesthetic match for the tragus with very minimal donor site deformity. The incisional scars were well placed parallel to the relaxed skin tension lines. Further cases are needed to establish the consistency of the blood supply, incidence of flap survival, and aesthetic result of the donor site and recipient areas. Publication Date: 10 March 2021 (online) © 2021. Association of Plastic Surgeons of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/). Thieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

Background: Merkel cell carcinoma (MCC) is a rare, aggressive cutaneous neuroendocrine malignancy. Like cutaneous malignant melanomas, a subset of MCCs can clinically present without an identifiable primary tumour, termed Merkel cell carcinoma of unknown primary (UPMCC), with incompletely understood behaviour and prognosis. Our objectives are to evaluate the clinical presentation, management and survival outcomes in UPMCC and compare overall survival with metastatic MCC of known-primary origin. Methods: A retrospective review of 252 consecutive MCC patients (1992–2023) identified 20 cases of histologically confirmed nodal or metastatic UPMCC. Demographics, anatomical distribution, treatment and oncological outcomes were analysed. Overall survival was compared with patients presenting with metastatic MCC of known primary. Results: The cohort included 15 males and 5 females (mean age 76 years). Presentation most commonly involved inguinal (n = 7) and axillary (n = 6) nodes, followed by parotid and cervical basins (n = 4). Management was multimodal, including lymphadenectomy, radiotherapy and systemic therapy. Six patients remained disease-free at a mean follow-up of 63.3 months. The mean overall survival was 43.65 months for UPMCC versus 39.29 months for known-primary metastatic MCC. Conclusions: UPMCC most commonly presents as inguinal or axillary nodal disease. Survival outcomes suggest a trend toward improved prognosis compared to known-primary metastatic MCC.