Summary Stress proteins represent a group of highly conserved intracellular proteins that provide adaptation against cellular stress. The present study aims to elucidate the stress protein-mediated effects of local hyperthermia and systemic administration of monophosphoryl lipid A (MPL) on oxygenation, metabolism and survival in bilateral porcine random pattern buttock flaps. Preconditioning was achieved 24 h prior to surgery by applying a heating blanket on the operative site ( n = 5), by intravenous administration of MPL at a dosage of 35 μg/kg body weight ( n = 5) or by combining the two ( n = 5). The flaps were monitored with laser Doppler flowmetry, polarographic microprobes and microdialysis until 5 h postoperatively. Semiquantitative immunohistochemistry was performed for heat shock protein 70 (HSP70), heat shock protein 32 (also termed haem oxygenase-1, HO-1), and inducible nitrc oxide synthase (iNOS). The administration of MPL increased the impaired microcirculatory blood flow in the proximal part of the flap and partial oxygen tension in the the distal part by ∼100% each (both P < 0.05), whereas both variables remained virtually unaffected by local heat preconditioning. Lactate/pyruvate (L/P) ratio and glycerol concentration (representing cell membrane disintegration) in the distal part of the flap gradually increased to values of ∼500 mmol/l and ∼350 μmol/l, respectively (both P < 0.01), which was substantially attenuated by heat application ( P < 0.01 for L/P ratio and P < 0.05 for glycerol) and combined preconditioning ( P < 0.01 for both variables), whereas the effect of MPL was less marked (not significant). Flap survival was increased from 56% (untreated animals) to 65% after MPL (not significant), 71% after heat application ( P < 0.05) and 78% after both methods of preconditioning ( P < 0.01). iNOS and HO-1 were upregulated after each method of preconditioning ( P < 0.05), whereas augmented HSP70 staining was only observed after heat application ( P < 0.05). We conclude that local hyperthermia is more effective in preventing flap necrosis than systemic MPL administration because of enhancing the cellular tolerance to hypoxic stress, which is possibly mediated by HSP70, whereas some benefit may be obtained with MPL due to iNOS and HO-1-mediated improvement in tissue oxygenation.