Ischemic preconditioning has been shown to improve survival of cutaneous flaps. The authors examined the effect of remote ischemic preconditioning (RIPC) on phosphorylation of p38 MAP kinase and related the results to flap survival. Female Wistar rats had 8 × 12-cm abdominal adipocutaneous flaps raised on the medial branch of the superficial epigastric artery. Controls (Group 1) had the flap elevated and the pedicle clamped for 3 hr, then closed with a sheet of plastic between the flap and abdominal wall. Group 2 animals had RIPC by tourniquet on the contralateral hind limb before the flap was dissected. Group 3 animals mimicked Group 2 and also had an infusion of the nitric oxide blocker, N-nitro-L-arginine methyl ester (L-NAME) 5 min prior to the RIPC. Group 4 had the flap elevated prior to the RIPC. All groups except Group 1 had 10 min of RIPC with 30 min of reperfusion, then 3 hr of ischemia. Tissue samples were taken at the distal margins of the flaps before preconditioning and 30 min after preconditioning for detection of p38 MAP kinase and phosphorylated p38 MAP kinase (pp38 MAP kinase). Group 2 flaps (RIPC before flap elevation) exhibited better flap tissue survival and had well-defined phosphorylation of p38 MAP kinase 30 min post RIPC, when compared to the other groups. Pre-infusion with the nitric oxide blocker (Group 3) before RIPC blocked the survival advantage conferred by preconditioning and diminished the phosphorylation of p38 MAP kinase. Tissue from all groups showed very little phosphorylation of p38 MAP kinase following 3 hr of ischemia. Thus, increased tissue survival is correlated with elevated levels of p38 MAP kinase phosphorylation following RIPC. This effect is inhibited by blockade of nitric oxide. Modulation of the p38 MAP kinase pathway may represent a protection pathway for ischemic preconditioning.