BURN SURGERY AND RESEARCH
Topical Application of Aloe vera Accelerated Wound Healing,
Modeling, and Remodeling
An Experimental Study
Ahmad Oryan, DVM, PhD,* Adel Mohammadalipour, DVM, PhD,Þ Ali Moshiri, DVM, PhD,þ
and Mohammad Reza Tabandeh, DVM, PhD§
Objective: Treatment of large wounds is technically demanding and several
attempts have been taken to improve wound healing. Aloe vera has been
shown to have some beneficial roles on wound healing but its mechanism on
various stages of the healing process is not clear. This study was designed to
investigate the effect of topical application of A. vera on cutaneous wound
healing in rats.
Methods: A rectangular 2  2-cm cutaneous wound was created in the dor-
sum back of rats. The animals were randomly divided into 3 groups of control
(n = 20), low-dose (n = 20), and high-dose (n = 20) A. vera. The control and
treated animals were treated daily with topical application of saline, low-dose
(25 mg/mL), and high-dose (50 mg/mL) A. vera gel, up to 10 days, respec-
tively. The wound surface, wound contraction, and epithelialization were
monitored. In each group, the animals were euthanized at 10 (n = 5), 20 (n = 5),
and 30 (n = 10) days post injury (DPI). At 10, 20, and 30 DPI, the skin samples
were used for histopathological and biochemical investigations; and at 30 DPI,
the skin samples were also subjected for biomechanical studies.
Results: Aloe vera modulated the inf lammation, increased wound contraction
and epithelialization, decreased scar tissue size, and increased alignment and
organization of the regenerated scar tissue. A dose-dependent increase in the
tissue level of dry matter, collagen, and glycosaminoglycans’ content was seen
in the treated lesions, compared to the controls. The treated lesions also
demonstrated greater maximum load, ultimate strength, and modulus of elas-
ticity compared to the control ones (P G 0.05).
Conclusions: Topical application of A. vera improved the biochemical, mor-
phological, and biomechanical characteristics of the healing cutaneous
wounds in rats. This treatment option may be valuable in clinical practice.
Key Words: Aloe vera, hydroxyproline, hexosamine, wound healing,
histopathology, biomechanics
(Ann Plast Surg 2016;77: 37Y46)
W ound healing is a complicated process and is composed of 3
overlapping phases including hemostasis and inf lammation,
proliferation or fibroplasia, and remodeling.1Y3 Wound healing is
often associated with the development of scar tissue formation that is
not cosmetically pleasant and also the biomechanical characteristics
Received December 27, 2013, and accepted for publication, after revision, March
26, 2014.
From the *Department of Pathology, School of Veterinary Medicine, Shiraz Univer-
sity, Shiraz; †Department of Clinical, Biochemistry, Medical School, Hamadan
University of Medical Sciences, Hamadan; ‡Division of Surgery, Department of
Clinical Sciences, School of Veterinary Medicine, Shiraz University, Shiraz; and
§Department of Biochemistry and Molecular Biology, Faculty of Veterinary
Medicine, Shahid Chamran University of Ahvaz, Ahvaz, Iran.
Conflicts of interest and sources of funding: none declared.
This study was funded by grants from the Shiraz University and Shahid Chamran
University.
Reprints: Ahmad Oryan, DVM, PhD, Department of Pathology, School of Veteri-
nary Medicine, Shiraz University, Shiraz, Iran. E-mail: oryan@shirazu.ac.ir.
Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/16/7701-0037
DOI: 10.1097/SAP.0000000000000239
Annals of Plastic Surgery & Volume 77, Number 1, July 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
of the healing wound is inferior to the normal skin which is important
for those wounds heal under tensional forces.1,2 Therefore, a good
wound healing agent is that to be effective to modulate the inf lam-
mation, accelerate fibroplasia, and enhance remodeling of the
healing tissue in minimum time with least adverse effects. The healed
wound should have least scar tissue size and highest biomechanical
performance to be pleasant clinically.4,5
Aloe vera (Aloe barbadensis Miller) is obtained from the par-
enchymatous cells in the fresh leaves of A. barbadensis. Aloe vera is
one of the best healer plants that has been used widely in the traditional
herbal medicine since many years ago.5,6 The immune modulatory,
anti-inflammatory, antiprotozoal, ultraviolet protective, and wound and
burn healing promoting properties of this plant has been previously
reported.7Y15 The A. vera leaves contain phytochemical components
such as acemannan, maloyl glucans, aloine, emodin, anthrones,
asarabinan, arabinorhamnogalactan, galactan, galactogalacturan,
lucogalactomannan, galacto glucoarabinomannan, glucuronic acid, and
various lectins.5,16Y19 In addition, A. vera consists of monosaccharides
(eg, glucose and fructose) and polysaccharides (eg, glucomannans and
acetylated mannan). These components have anti-inflammatory and
immune modulating activities.11,14,20 Acetylated polymannan,
acemannan, mannose monomer/acetyl, and aloeride have been shown
to stimulate macrophages, killer T cells, and cytokine production. They
increase blood CD8+, IL-2, and IFN-c levels; decrease CD4+/CD8+;
and induce the expression of the mRNAs encoding IL-1A and TNF->.
They also have anti-inflammatory effects because they decrease the IL-5
and IL-10 and down-regulate the MMP-9.12,13,20Y24
The acetylated glucomannan, located within the protoplast of
the parenchyma cells, is a mannose-rich polysaccharide with gib-
berellin, a growth factor, interacts with growth factor receptors on the
fibroblast, stimulates its activity and proliferation, and results in
significant increase of collagen synthesis.6,16 Three malic acid ac-
ylated carbohydrates have been isolated from the A. vera gel and
characterized as veracylglucan A to C.17 Veracylglucan B has potent
anti-inf lammatory and antiproliferative effects; veracylglucan C, on
the other hand, has significant cell proliferative and anti-
inf lammatory activities. Veracylglucan B and C have been reported
to be antagonistic and competitive in their effects on cell prolifera-
tion.17 This plant also dose dependently stimulates the macrophages
to release IL-1, IL-6, TNF->, and IFN-F.13,25
It has been shown that A. vera gel not only increases collagen
content of the healing wound but also changes the collagen compo-
sition and increases the degree of collagen cross-linking.15,26 In ad-
dition, increased synthesis of hyaluronic acid and dermatan sulfate in
the granulation tissue of a healing wound after oral or topical ad-
ministration of A. vera has been reported.27 The angiogenesis and
oxygen access are other factors enhanced by the A. vera gel.28,29 It
has been shown that superoxide dismutase and glutathione peroxi-
dase are present in A. vera gel, which may be responsible for its
antioxidant effects.9 Moreover, A. vera has been shown to inhibit
prostaglandin E2 production by inhibiting cyclooxygenase.23 Al-
though most of the investigations have reported the beneficial effects
www.annalsplasticsurgery.com 37
Oryan et al
of A. vera,6,15,26,27 some others suggest that A. vera may retard
wound healing.30Y32
Given the previously mentioned explanations, this study was
designed to investigate the effect of topical application of A. vera gel
on the healing of an experimentally induced large cutaneous wound
defect in rats. We hypothesized that (1) A. vera may enhance the rate
and quality of inf lammation by increasing the macrophages, thus
may reduce its duration. (2) Aloe vera may increase the quality of
fibroplasia at midterm and this may enhance the quality of remod-
eling at long-term. (3) If A. vera was effective on different stages of
wound healing and improves the structure of the healing tissue, the
healed wound is expected to have higher biomechanical performance
than the controls. (4) Aloe vera may exert its beneficial effects on
wound healing dose dependently.
MATERIALS AND METHODS
Ethics
The investigators who undertook the measurements and anal-
yses of the results were unaware of the experimental design and
grouping details. The same surgeon performed all the operative
procedures. All animals received humane care in compliance with the
Guide for Care and Use of Laboratory Animals published by the
National Institutes of Health (NIH publication No. 85-23). The local
Ethics Committee of our faculty approved the study.
Experimental Animals
Sixty adult mature male Wistar rats weighing 250 (50) g were
purchased from a certified laboratory animal house. The animals
were kept individually in standard rat cages and had free access to
commercial pellet food and water. All the standard temperature, hu-
midity, and light cycle were provided for the experimental animals.33
Preparation of A. vera Gel
Full-sized mature leaves of A. vera, cultivated in botany gar-
den, were cut and the rind was removed. The colorless parenchyma
was ground in a blender and centrifuged at 10,000g for 30 minutes at
4-C to remove the fibers. The A. vera was freeze-dried and
transformed to powder. This increased the shelf life of the A. vera.34
Before in vivo experimentation and topical application of the A. vera
on rat cutaneous wounds, the A. vera powder was dissolved in sterile
saline 0.9% to produce a solution with the concentrations of 25
and 50 mg of A. vera per milliliter of saline. The biologic activity
of the A. vera solution with the doses of 25 and 50 mg/kg on mo-
lecular aspects of wound healing has been previously shown and
confirmed.34
Injury Induction
The animals were anesthetized by intramuscular injection of
2 mg/kg xylazine HCl as premedication and 60 mg/kg ketamine HCl
(both from Alfasan, Woerden, the Netherlands) for anesthesia.33 This
type of anesthesia prevents movement of the animals at least for
10 minutes after administration of the anesthetic solution; therefore, the
animals were left without being restrained. Before making incisions,
hairs of the dorsum back were clipped and scrubbed. Under aseptic
condition, a rectangular full-thickness skin (2  2 cm) including
epidermis, dermis, and subcutaneous fat was incised, dissected, and
removed to create a wound defect on the dorsum back of the rats.
Study Design and Therapeutic Regimens
The animals were randomly divided into 3 groups of control
(n = 20), treated with low-dose A. vera (n = 20) and treated with
high-dose A. vera (n = 20). The animals of the control group were
treated daily by topical application of isotonic 0.9% saline for 10 days.
The treated animals were treated daily by topical application of low
dose of A. vera (25 mg A. vera in 1 mL saline) and high dose of A.
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Annals of Plastic Surgery & Volume 77, Number 1, July 2016
vera (50 mg A. vera in 1 mL saline) for 10 days, respectively. Gross
morphology of the wound area of all the animals was assessed daily.
Each group was then divided into 3 groups of 10 (n = 5), 20 (n = 5),
and 30 (n = 10) days post injury (DPI). The biochemical and histo-
logical examinations of the lesions of animals of all the groups were
conducted at 10, 20, and 30 DPI. In addition, biomechanical char-
acteristics of the skin samples of the 30 DPI was also tested (n = 5
for each group).
Gross Morphology of the Wounds
The wound area was observed and photographed daily. The
photographs were transferred to Scion image software for morpho-
metric analysis including measurement of the wound diameter and
calculation of the wound surface area. Percentage of wound con-
traction was then calculated by the following equations:
Wound area (%) = (Wound area at X DPI/wound area at 0 DPI)  100
Percent of contraction at X DPI = 100 j percent wound area at X DPI
Euthanasia
The animals were euthanized by intracardiac administration of
50-mg/kg sodium thiopental and 1-mg/kg pancuronium (Pavulon Ink
Co, USA) to induce coma and stop breathing, respectively.
Sample Collection
The full-thickness skin samples were dissected and harvested
from the wound site and were assessed for histological studies and
biochemical analyses (n = 5 at each time interval in each group). The
samples were longitudinally divided into 2 equal parts. A half was
used for histopathological evaluations (including the intact healthy
skin at periphery of the wound site and the injured healing area just in
the wound site) and another half (only the injured healing area) was
used for determination of the dry matter content and biochemical
analyses. At 30 DPI, a rectangular skin sample of 3  10 cm in-
cluding the injured area was harvested for biomechanical evaluation
(n = 5 for each group at 30 DPI).33 Another 5 intact skin samples
were harvested from the contralateral part and were tested for bio-
mechanical testing as an index of normal healthy skin.
Histopathologic and Histomorphometric Analysis
After fixation in 10% neutral buffered formalin, blocks of the
skin were washed, dehydrated in a graded series of ethanol, cleared
and embedded in paraffin wax, sectioned at 5 Km in thickness,
stained with hematoxylin and eosin, and examined by a light mi-
croscope (Olympus, Tokyo, Japan). The photomicrographs were then
recorded by a digital camera (Sony T-700, Tokyo, Japan) and trans-
ferred to the computer software (Adobe Photoshop CS-5, Calif ) for
digital analyses. Five photomicrographs equivalent to 5 microscopic
fields from each tissue section were used for histopathologic and
histomorphometric analysis.35
Total cellularity (200), and number of fibroblasts, fibrocytes,
neutrophils, lymphocytes, macrophages, and blood vessels of the
injured area were counted (800). The mesenchymal cells in the
injured area were divided into 2 categories based on their diameter,
cytoplasmic granules, and cell staining capacities. The largest ellip-
tical cells with high granular and basophilic cytoplasm were assessed
as fibroblasts. The long, cigar-shaped cells with less granulated but
more eosinophilic cytoplasm and having small nucleus/cytoplasm
ratio were estimated as fibrocyte.35 The caliber of the blood vessels
was measured in digital photomicrographs, using computer software
measuring system (Adobe Photoshop CS-5 extended, Calif ). In ad-
dition, the wound surface, tissue alignment, tissue maturation, vas-
cularity, and perivascular edema were assessed and scored according
to Tables 1 and 2.
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Annals of Plastic Surgery & Volume 77, Number 1, July 2016 Topical application of Aloe vera

TABLE 1. Scoring Criteria Used for Defining the Wound Surface, Tissue Alignment, and Tissue Maturation
Score Morphology of Epidermis Distance Between Wound Edge, Km
1. Wound surface
0, Near normal Completely regenerated 9500
1, Highly mature G80% regenerated 91000
2, Mature G50% regenerated 92000
3, Immature G20% regenerated 9500
4, Highly immature No epidermis formed G2000
Score Direction of Collagen Direction of Fibroblast
2. Tissue alignment
0, Near normal Almost in 1 direction Parallel collagen fiber
1, Highly mature Mostly in 1 longitudinal direction, but with G75% in direction of collagen fibers
few areas of unrecognized collagen fibers
2, Moderately mature More than 1 longitudinal direction G50% in direction of collagen fibers
3, Immature Irregular orientation: collagen fibers have G50% in direction of collagen fibers
some orientation but orientation is not
longitudinal (eg, circular pattern)
4, Highly immature No diagnostic orientation No orientation
Score Cellular Populations Appearance of Collagen Fibers
3. Tissue maturation
0, Near normal G75% fibrocyte G75% of collagen fibers are dense and have large size
1, Highly mature G50% fibrocyte G50% of collagen fibers are dense and have large size
2, Moderately mature G25% fibrocyte G75% of collagen fibers are dense and have medium size
3, Immature G75% fibroblasts Collagen fibers are not dense, but are medium sized
4, Highly immature Inflammatory cells predominant Collagen fibers are not dense, but are small sized

Biomechanical Testing Percentage Dry Weight

The method has been previously described by Oryan and col-
leagues.35 Brief ly; the injured skin and their related contralateral skin
from 5 animals in each group were dissected and stored for 3 days
at j20-C. Before the tensile testing, the specimens were defrosted
at room temperature. Each skin sample was mounted between the
2 cryoclamps of a tensile testing machine (Instron Tensile Testing
Machine, London, UK). Testing to failure was then conducted. Each
sample was loaded by elongating it at a displacement rate of
20 mmsj1. Load and crosshead displacement data were recorded at
1500 Hz, and the load-deformation and stress-strain curves were
generated for each specimen, using Test Works 4 software (SUME
Systems Corporation).35 The maximum load, yield load, ultimate
strain, yield strain, maximum stress, and modulus of elasticity of the
samples were extracted from the curves and statistically analyzed.
The percentage dry matter of the harvested skin samples was
calculated according to the following equation: Percentage dry matter
content = (dry weight/wet weight)  100.36
Biochemical Analyses
Estimation of hydroxyproline and collagen content was done
as described previously.37 Brief ly, the excised granulation tissues
were weighed, defatted in chloroform/methanol mixture (2:1 vol/vol),
hydrolyzed in 6.0 N HCl for 18 hours at 110-C, and evaporated to
dryness. The hydrolysate was neutralized to pH 7.0 and subjected to
chloramine-T oxidation; all the test tubes were placed in a water bath
at 60-C for 20 minutes. The reaction was terminated by addition of
1 mL (0.4 M) perchloric acid; the color was developed by adding 1-mL
paradimethylaminobenzaldehyde and was read spectrophotometrically

TABLE 2. Scoring Criteria Used for Defining Vascularity and Perivascular Edema
Score Description
1. No. vessels and their diameter (vascularity)
0, Near normal Up to 4, all with and diameter
1, Highly mature 5Y10 vessels; 70% are large
2, Mature 11Y20 vessels; 50% are large
3, Immature 21Y30 vessels; G20% are large, with the rest of small size
4, Highly immature 930 vessels, almost of small size
2. Perivascular edema (observed in an 10 objective field)
0, Normal No edema is seen around the vessels
1, Mild Presence of edema around small vessels
2, Moderate Presence of edema around medium vessels
3, Severe Presence of edema around large vessels

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Oryan et al Annals of Plastic Surgery & Volume 77, Number 1, July 2016

at 557 nm. The amount of hydroxyproline in each sample was mea-
sured, using the regression curve from the hydroxyproline standards
(0.0, 0.5, 1.0, 2.0, 4.0, and 6.0 mg hydroxyproline) and reported as mg/
100 mg tissue. The collagen content was estimated from the hydroxy-
proline concentration of each tissue sample by multiplication in the
factor 7.46.38 n-Acetyl glucosamine (NAGLA) and n-acetyl galactos-
amine (NAGA) concentrations of the dry granulation tissues were
measured by the method of Reissig et al.39 Briefly, alkaline hydrolysate
was converted into pyrrole derivatives by acetyl-acetone and subse-
quently treated with paradimethylaminobenzaldehyde to a red solution
which was measured at 585 nm by spectrophotometry.
Statistical Analysis
To statistically analyze differences between multiple groups at
1 time point, 1-way analysis of variance (ANOVA) with its subse-
quent post hoc Tukey tests were used; and between multiple groups at
2 time points, 2-way ANOVA with its subsequent post hoc Tukey
tests were used. The scoring values were statistically analyzed, using
the Kruskal-Wallis nonparametric test and Mann-Whitney U tests
were performed to test the significant differences between the groups.
Statistics were performed using the computer software SPSS version
21 for windows (SPSS Inc, Chicago, Ill). A value of P of less than
0.05 was considered statistically significant. The quantitative results
were expressed as mean (SD) and the scoring results were expressed
as median (min-max).
RESULTS
Macroscopic Findings
At 15 DPI, treatment with high dose of A. vera almost closed
the wounds completely, whereas the lower dose of A. vera was able to
close the wounds at 20 DPI. In the control lesions, the wound was
completely closed at 26 DPI (Fig. 1). Treatment with high dose of A.
vera significantly increased the percentage of wound contraction at
10, 15, and 20 DPI (P = 0.001 for all) compared to the control le-
sions. Also, those lesions treated with high dose of A. vera showed
significantly higher percentage of wound contraction at 15 and 20
DPI compared to the treated rats with low dose of A. vera (P = 0.001
for both). Treatment with low dose of A. vera significantly increased
the percentage of wound contraction compared to the control lesions
at 10, 15, and 20 DPI (P = 0.001 for all) (Fig. 2A). In general, the
treated wounds with the low and high doses of A. vera had higher
granulation tissue during the first 10 days after injury; and compared
to the controls, the granulation tissue developed earlier and organized
as scar tissue at later stages of wound healing. In the treated groups,
the size of scar tissue gradually decreased time dependently (at 20
and 30 DPI) so that wound contraction and epithelialization had oc-
curred better and faster than the controls. Therefore, the healing
treated wounds had better cosmetic appearance at 30 DPI than the
control lesions and these beneficial characteristics of the A. vera was
found to be dose dependent because those wounds treated with the
higher dose of A. vera had better cosmetic appearance and less scar
tissue size than the treated wounds with low dose of A. vera. No
wounds became infected and normal healing response occurred in all
the wounds.
Histopathological Findings
The qualitative report has been expressed in Figures 3 and 4.
Treatment with high dose of A. vera significantly reduced total cel-
lularity and significantly increased number of fibrocytes (as the
mature mesenchymal cells) and macrophages (as the most important
inf lammatory cells) compared to the lesions treated with low dose of
A. vera and the control lesions at 10 DPI (P = 0.001 for all). This
dose also significantly increased the collagen mass density and the
number and diameter of the blood vessels and decreased the number
of the lymphocytes compared to the control lesions at this stage (P =
0.001 for all). At this stage, treatment with a low dose of A. vera
significantly increased the diameter and number of the blood vessels,
number of the fibrocytes and macrophages, and collagen mass den-
sity (P = 0.001 for all) and significantly decreased the total cellularity
and number of the lymphocytes compared to the control lesions (P =
0.001 for all; Table 3; Figs. 3A, D, G and 4).

FIGURE 1. Wound surface of the control (A, D), low-dose A. vera (25 mg/mL) (B, E), and high-dose A. vera (50 mg/mL) (C, F), at 15
DPI. The A. vera dose-dependently increased wound contraction and closure. The margins of the wound are indicated by the
arrows in the inverted images (DYE). The wound shape is trapezium, elliptic, and circular in the control, low-, and high-dose A. vera,
respectively, suggesting the groups treated with A. vera are in a more advanced stage of wound contraction.

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Annals of Plastic Surgery & Volume 77, Number 1, July 2016
FIGURE 2. Aloe vera dose-dependently increased the percentage of wound contraction (A) and dry matter content of the healing
tissue (B). A dose-dependent increase in the tissue level of the collagen (C), NAGLA (D), and NAGA (E) was seen in the treated
lesions compared to the controls.
High dose of A. vera significantly decreased the total cellu-
larity and increased the diameter of blood vessels at 20 DPI com-
pared to the lesions treated with the low dose of A. vera (P = 0.001
for all). This treatment regimen also significantly decreased total
cellularity, number of fibroblasts (as the immature mesenchymal
cells), lymphocytes, and macrophages and significantly increased the
diameter of the blood vessels, number of fibrocytes, and collagen
mass density compared to the control ones. Low dose of A. vera also
significantly decreased total cellularity, number of fibroblasts and
macrophages, and it also significantly increased diameter of the
blood vessels, number of fibrocytes, and collagen mass density
compared to those in the control ones (P = 0.001 for all; Table 3;
Figs. 3B, E, H and 4) at this stage.
At 30 DPI, treatment with high dose of A. vera significantly
decreased total cellularity, number of fibroblasts and significantly in-
creased the diameter of blood vessels and number of fibrocytes com-
pared to the lesions treated with the low dose of A. vera (P = 0.001 for
all). High dose of A. vera also significantly decreased total cellularity,
number of blood vessels, fibroblasts, lymphocytes, and macrophages
and significantly increased the diameter of blood vessels, number of
fibrocytes, and collagen mass density compared to the control lesions
(P = 0.001 for all). At this stage, treatment with low dose of A. vera
significantly decreased number of immature blood vessels, fibroblasts,
and macrophages and significantly increased the diameter of blood
vessels, number of fibrocytes, and collagen mass density compared to
the control lesions (P = 0.001 for all; Table 3; Figs. 3C, F, I and 4).
Treated lesions with high dose of A. vera showed significantly
superior scored values for the wound surface area (Table 1) compared to
the treated lesions with low dose of A. vera and the control lesions at 10
DPI [0.5 (0Y2)A. vera high dose vs 1.5 (1Y3)A. vera low dose vs 3 (2Y4)Control,
P = 0.001 for both]. At this stage, the treated lesions with high dose of
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Topical application of Aloe vera
A. vera also significantly gained superior scored values for the vascu-
larity [0.5 (0Y2)A. vera high dose vs 1.5 (1Y4)A. vera low dose vs 3.5 (3Y4)Control,
P = 0.001 for both] and perivascular edema [0 (0Y1)A. vera high dose vs 1.5
(1Y3)A. vera low dose vs 2.5 (2Y3)Control, P = 0.001 for both] compared to
the lesions treated with low dose of A. vera and the control lesions
(Table 2). At 30 DPI, the newly formed scar tissue in the treated lesions
with high dose of A. vera showed significantly superior scored values
for the alignment (Table 1) compared to the treated lesions with low
dose of A. vera and the control lesions [0.5 (0Y1)A. vera high dose vs 2.5
(1Y3)A. vera low dose vs 3.5 (1Y4)Control, P = 0.001 for both]. At this stage,
the treated lesions with high dose of A. vera also showed significantly
superior scored values for the tissue maturation (Table 1) compared to the
lesions treated with low dose of A. vera and the control lesions [0.5
(0Y1)A. vera high dose vs 1.5 (1Y2)A. vera low dose vs 3.5 (2Y4)Control, P = 0. 001
for both].
In general, treatment with high dose of A. vera accelerated the
rate and quality of inf lammation and fibroplasia so that at short-term
(day 10) more granulation tissue developed and filled the wound area
when compared to the controls. Compared to controls, A. vera or-
ganized the granulation tissue and produced a scar tissue faster than
the controls at 20 DPI. In addition, A. vera decreased the size of the
scar tissue by aligning the newly developed collagen fibers and cel-
lular structures at 30 DPI. The treated lesions with either the low or
high doses of A. vera showed superior quality of wound contraction
and epithelialization when compared to the control lesions at various
stages of wound healing. These effects were dose dependent.
Biomechanical Performance
As it has been shown in Table 4, treatment with high dose of
A. vera significantly increased the maximum load of the treated le-
sions compared to the control lesions (P = 0.013), at 30 DPI.
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Oryan et al Annals of Plastic Surgery & Volume 77, Number 1, July 2016

FIGURE 3. Longitudinal sections of the control lesions (A, day 10; D, day 20; G, day 30), lesions treated with 25 mg/mL of A. vera
(B, day 10; E, day 20; H, day 30), and those treated with 50 mg/mL of A. vera (C, day 10; F, day 20; I, day 30). Scale bars of (A) to (I)
are equal to 50 Km. During wound healing, A. vera dose-dependently reduced cellularity and inf lammation at 10 DPI but also
increased epithelialization and granulation tissue formation at 20 DPI; and finally, it enhanced remodeling of the scar tissue by
aligning the collagen fibers and cells at 30 DPI. Therefore, A. vera improved regeneration and maturation of the epithelial tissue
and reduced size of the scar tissue at 30 DPI. Stained by hematoxylin and eosin.

However, the maximum load of all the lesions were significantly
lower than the intact healthy skin samples at this stage (P = 0.001 for
all). Treatment with high dose of A. vera significantly increased the
maximum stress of the healing treated tissue compared to the control
lesions (P = 0.018), but there was no significant difference in the
maximum stress of the lesions treated with low dose of A. vera and
the control lesions at this stage (P 9 0.05). Although treatment with
high dose of A. vera significantly increased the maximum stress; the
measured value was still significantly lower than that of the intact
healthy skin samples at this stage (P = 0.001). Treatment with high
dose of A. vera also significantly increased the modulus of elasticity
of the treated lesions when compared with the control lesions at 30
DPI (P = 0.006). There was no significant difference between the
modulus of elasticity of the lesions treated with high dose of A. vera
and those treated with low dose of A. vera at this stage (P 9 0.05).
The modulus of elasticity of the lesions treated with high dose of A.
vera was also significantly lower than those of the intact healthy skin
samples (P = 0.001) at this stage.
Dry Matter Content
Treatment with high dose of A. vera significantly increased the
percentage dry matter content compared to the control ones at 20 and
30 DPI (P = 0.001 for both). Although the high dose of A. vera
significantly improved the dry matter content, the measured value for
the treated lesions was still significantly lower than those of the intact
normal skin samples (P = 0.001) (Fig. 2B) at this stage.
Biochemical Findings
A dose-dependent increase in the tissue level of collagen (Fig. 2C),
NAGLA (Fig. 2D), and NAGA (Fig. 2E) was seen in the treated lesions
so that topical application of low-dose A. vera significantly increased
the concentration of collagen and glycosaminoglycans compared to
the control lesions at 10, 20, and 30 DPI (P = 0.001 for all) and treat-
ment with high dose of A. vera significantly increased these items
compared to those treated with low dose of A. vera at 10, 20, and 30 DPI
(P = 0.001 for all).
DISCUSSION
Several studies have reported the anti-inf lammatory, cell pro-
liferative, immune modulating, collagen stimulatory, antioxidative,
and angiogenic activity of A. vera; however, some controversies exist
between these studies that make the real efficacy of A. vera
unclear.5,6,8,9,11Y18,20,21,24Y27,30Y32,40 These controversies could ini-
tially be due to the design of the studies. For example, Oryan and
colleague26 studied the effect of A. vera on wound healing by brief
histopathologic and tensile testing methods. Some others studied the

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Annals of Plastic Surgery & Volume 77, Number 1, July 2016 Topical application of Aloe vera

FIGURE 4. Longitudinal sections of the control (A, D), 25 mg/mL of A. vera (B, E), and 50 mg/mL of A. vera (C, F) at 30 DPI. A to C
are stained by hematoxylin and eosin. D to F are inverted figures for better clarification of the structures. Scale bars of (A) to (C) are
equal to 12.5 Km and (D) to (E) are equal to 6.25 Km. Aloe vera dose-dependently reduced the immature fibroblasts and
inf lammatory cells but also enhanced maturation and alignment of the fibroblasts at 30 DPI so that more mature fibrocytes were
present in the treated lesions compared to those of the control ones.

role of A. vera on tissue level of hyaluronic acid and dermatan sul-
fate27 and some others focused on the angiogenic and oxygen access
effects of A. vera.29,40 The major merit of the present study was that
various methods were used to study the different roles of A. vera on
cutaneous wound healing in rats to test whether there is a correlation
between the results and to show whether A. vera has dose-dependent
effect on wound healing.
We showed that A. vera significantly increases the rate of
wound contraction, epithelialization, and maturation. Higher dose of
A. vera was also effective in increasing the maximum load and ulti-
mate strength of the healing tissues compared to other groups. These
beneficial changes could be initially due to the modulatory effects of
A. vera on the inf lammatory phase of wound healing.23 At the earlier
stages of wound healing, the reduced total cellularity, edema, and
fibrin clot together with the elevated number of macrophages, fi-
broblasts, and large blood vessels observed in the treated lesions,
compared to the controls, suggest that A. vera enhances the rate and
quality of the inf lammatory phase of wound healing.23 Increase in
the number of blood vessels in the treated lesions could indicate the
angiogenic activity of A. vera at earlier stages of wound healing
which established a better perfusion and appropriate circulation in
the injured area. Angiogenic activity of A. vera has previously been
reported.40 Introduction of sufficient blood f low in the injured area
increased the number of the endothelial cells, macrophages, and fi-
broblasts and further enhanced maturation of the fibroblasts which
resulted in increased collagen production by these cells.23
Compared to the control group, lower number of lymphocytes
and higher number of macrophages observed in the treated group at
earlier stages of wound healing indicate that this reagent has selective
and modulatory effects on inf lammation during wound healing.4
Lymphocytes are chronic inf lammatory cells and have fewer roles on
wound healing than the macrophages. In contrast, the macrophages
regulate several beneficial mechanisms during wound healing such as
phagocytosis of the fibrin clot and necrotic tissues in the injured ar-
ea.4,13,23 They also deliver the angiogenic and growth factors and
increase migration and proliferation of the endothelial cells and fi-
broblasts, thus facilitate the transition between the inf lammation to
fibroplasia.28,41 Possibly A. vera increased the rate and quality of
inf lammation by increasing the macrophages and reduced its dura-
tion by decreasing the lymphocytes.33
The extracellular matrix that is produced by fibroblasts is
made up of collagen, glycosaminoglycans, and elastin.28 Our results
indicated that higher number of fibroblasts and fibrocytes at different
stages of wound healing had a strong positive correlation with the
tissue level of collagen and glycosaminoglycans and A. vera in-
creased the amount of these items in the healing treated tissues
compared to the unassisted control lesions.
At earlier stages of fibroplasia the newly deposited extracel-
lular matrix mainly consists of glycosaminoglycans with lower pro-
portion of collagen type III.4,28 Collagen type III is an immature form
of collagen and its collagen fibrils have smaller diameter than those
of the mature type 1 collagen fibrils. The cross-link bonds between
these collagen molecules are weak, and they are polymerized at
multidirections and represent an amorphous appearance in the
regenerated tissue. The glycosaminoglycans have crucial roles on
wound healing and act as a scaffold for collagen fiber polymerization
and also incorporate in collagen maturation.41 Compared to the
controls, A. vera dose-dependently increased the tissue level of
glycosaminoglysans specially at the fibroplasia stage of wound
healing. These findings are in line with those of Chithra et al,27 who
showed that A. vera increases the amount of glycosaminoglycans in
the injured area. Unlike the treated lesions, presence of neutrophils
and numerous macrophages and lymphocytes in the untreated tissues
at fibroplasia stage suggest that the unassisted wound healing was at
the earlier stages of healing and the chronic inf lammation was still in
progress, whereas the inf lammation had subsided earlier in the
treated lesions.14
Once the tissue level of glycosaminoglycans increased and the
fibroblasts proliferated, these cells become mature and their behavior
would change.4,28 At mid to late stages of fibroplasia, their matrix

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Oryan et al Annals of Plastic Surgery & Volume 77, Number 1, July 2016

A. vera, 50 mg

For the statistical analyses, 1-way and 2-way ANOVA were used. Post hoc Tukey tests were used for comparison between the groups. Statistics were considered statistically significant when P G 0.05. For each evaluation, 5 his-
topathologic fields of each histopathologic section (n = 5) were used in each group. There are 5 animals in each group. Lymphocytes, macrophages, and neutrophils were counted as an index of inf lammation. Total cellularity was
118.80 (20.16)
production is shifted from glycosaminoglycans to collagen produc-

1.01 (1.22)

5.62 (1.51)
5.80 (2.58)
2.66 (1.14)
87.62 (4.50)
49.69 (2.96)

88.51 (4.18)
tion.4,28 At this time, the tissue level of the glycosaminoglycans

0
decreases and the collagen content increases.4,27,41 By increasing
the collagen content of the healing tissue, a scar tissue forms and the
tissue becomes mature.4,41 The total cellularity decreases and the
Day 30 After Injury

fibroblasts transform to fibrocytes. In addition, several immature

A. vera, 25 mg
157.28 (15.83)

blood vessels disappear and the few preserved blood vessels are
2.12 (1.58)
46.36 (4.25)
26.48 (2.96)
8.81 (1.12)
9.48 (2.30)
3.68 (1.14)

80.18 (7.99)
canalized, receive blood supply, their caliber increases and approxi-
mate to the normal blood vessels.4 The scar tissue then becomes

0
more organized by time and its unorganized structure changes to a
highly aligned pattern. In such circumstance, the collagen fibers be-
come thicker, the quantity and quality of their cross-links improve,
and the amount of collagen type III diminishes and shifts to forma-
Control Saline
196.68 (23.89)
TABLE 3. Histopathologic and Histomorphometric Analysis: Comparison Between the Control, Low Dose, and High Dose of A. vera

8.15 (1.68)
31.66 (1.49)
11.12 (3.48)
15.49 (1.51)
14.47 (2.35)
7 (2.39)

62.01 (5.42)
tion of higher amounts of collagen type I concentration.10,41 The
matured collagen fibrils are aligned unidirectionally in accordance to
0

the forces transmitted through the wound, during healing. Therefore,

in the remodeling phase of wound healing, size of the scar tissue
decreases because the collagen fibers are aligned and the free spaces
between them decrease.4,28
A. vera, 50 mg

10.20 (1.64)
202.60 (9.01)

57.88 (2.46)
28.80 (1.48)
11.29 (1.64)
7.47 (1.14)
7.40 (1.81)

80.32 (6.18)

At 30 DPI, our results suggest that A. vera significantly re-

duced the total cellularity and immature blood vessels. It also in-
0

creased fibrocytes and caliber of the blood vessels and enhanced

alignment of the collagen fibers in the injured area. Aloe vera also
significantly increased the tissue level of collagen and dry matter
Day 20 After Injury

content compared to the controls. In addition, it interestingly de-

A. vera, 25 mg

creased the scar size at this stage. The remodeling phase could be
241.29 (25.35)
12.61 (1.67)
38.83 (5.20)
15.29 (3.56)
14.27 (3.27)
9.41 (2.60)
8.88 (2.16)

74.92 (6.71)

divided into 3 stages of alignment, maturation, and consolidation.

On the basis of the results of the present study, the treated wounds at
0

30 DPI were in the alignment and maturation stages of wound

healing because the epidermis was fully regenerated, the wound
contraction completely occurred, and the wounds closed. In addition,
the scar tissue formed in the injured area was aligned and mature. The
Control Saline
288.64 (12.35)
11.65 (1.88)
23.42 (1.83)
6.11 (2.76)
24.28 (1.35)
11.22 (2.34)
21.65 (1.34)

51.29 (3.18)

consolidation stage of wound remodeling lasted up for months. In

this stage, the healing tissue may gain almost its normal mechanical
0

strength.42
All these results suggest that A. vera improved the structural
organization of the healing tissue and this enhanced hierarchical or-
ganization was responsible for the superior biomechanical perfor-
A. vera, 50 mg
296.60 (24.65)

mance of the healing treated tissues compared to the controls.

21.6 (3.28)
26.55 (5.88)
17.00 (1.58)
19.23 (2.12)
12.20 (4.32)
28.08 (4.33)
0.89 (0.44)
75.16 (6.24)

Increase in the maximum load, maximum stress, and modulus of

elasticity of the treated wounds indicated that A. vera not only in-
creased collagen synthesis per cell but also aided in cross-linking and
maturation of the collagen fibrils and fibers. The effect of A. vera in
increasing the mechanical strength of the healing tissue has major
Day 10 After Injury
A. vera, 25 mg

clinical relevance to those clinically injured wounds which heal under

384.21 (13.88)
18.25 (3.49)
21.34 (2.86)
9.81 (0.83)
15.49 (3.64)
18.43 (2.96)
17.66 (2.88)
0.21 (0.44)
62.18 (8.91)

tensional forces. Under tension, there is a risk of dehiscence and

healing failure and the role of A. vera in increasing the mechanical
strength of the healing tissue should be highlighted.33
counted at 200. The other variables were counted at 800.

At 30 DPI, A. vera enhanced the cosmetic appearance of the

healing wounds dose dependently. The A. vera exerted this beneficial
effect by increasing the wound contraction and epithelialization,
Control Saline
471.22 (16.14)
7.62 (1.53)
12.33 (2.79)
3.49 (1.16)
21.04 (5.56)
25.43 (5.78)
8.56 (2.79)
0.85 (0.27)
45.27 (5.18)

which resulted in a faster wound closure, and by decreasing the size

of scar tissue through accelerating its organization and remodeling.
The role of A. vera in improving the cosmetic appearance of the
experimental wounds has major clinical relevance. It should be
highlighted that, in this study, the experimentally induced wounds
were surgically created under aseptic condition in a rat model. This
Collagen mass density,%

model of wound has least postsurgical complication and is best suited

Diameter of vessel, Km

to compare the effectiveness of biomaterials and healing factors on

Macrophage number
Lymphocyte number

Neutrophil number
Variables/Groups

Fibroblast number
Fibrocyte number

normal wound healing. The clinical wounds are often more compli-
Vascular number
Total cellularity

cated and are presented in different conditions. They may be larger,

infected and gangrenous, burned, or may have chronic nature. In
addition, the rate of wound healing is faster in laboratory animal
models due to their faster maturation. Therefore, it may take months
to judge about the cosmetic appearance of the clinical wounds in

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Annals of Plastic Surgery & Volume 77, Number 1, July 2016
TABLE 4. Biomechanical Characteristics of the Wound Samples
Biomechanical Factors Control
Maximum load, N 20.60 (2.70)
Ultimate strain, % 36.97 (14.26)
Yield strain, % 29.8 (9.69)
Yield load, N 14.92 (3.56)
Ultimate strength, N/mm2 1.10 (0.48)
Modulus of elasticity, N/mm2 0.03 (0.01)
For the statistical analyses, 1-way and 2-way ANOVA were used. Post hoc Tukey tests were used for comparison between the groups. Statistics were considered significant when P G
0.05. There are 5 samples in each group.
response to treatment with A. vera because the healing rates of these
complicated wounds are possibly slower than the experimental
wounds used in the present study.42
Although this study comprehensively investigated the role of
A. vera on experimental cutaneous wound healing and provided new
insights in this regard, the potential physiologic variations between
human and animals should be considered as one of the limitations of
this study. In addition, this study used 3 time points to cover all the
3 phases of wound healing but it should be remembered that the re-
modeling phase of wound healing takes longer time to be completed;
therefore, longer observational times (eg, 60 and 120 DPI) are needed
to show the final outcome of the A. vera on remodeling phase of
wound healing and also the cosmetic appearance of the healing
wounds. Finally, we used A. vera with the concentrations of 25 and
50 mg/mL that were based on the molecular effects of A. vera during
wound healing.34 It would be beneficial to compare the effectiveness
of higher doses of A. vera on cutaneous wound healing with the re-
sults of the present study in future investigations.
CONCLUSIONS
Topical application of A. vera modulated the inf lammation,
increased the rate and quality of fibroplasia by enhanced collagen
and glycosaminoglycans production, and improved the remodeling
stage of the healing tissue. The lesions treated by A. vera showed
dose-dependent improvement at various stages of wound healing so
that the treated lesions showed faster wound contraction, enhanced
epithelialization, smaller scar tissue formation, and higher tissue
alignment. A dose-dependent effect of A. vera was shown in this
study. The role of A. vera in increasing the cosmetic appearance and
biomechanical characteristics of the healing cutaneous wounds has
important clinical relevance and should be highlighted. These find-
ings introduce A. vera as one of the best therapeutic agents in wound
healing and it may be valuable in clinical practice.
ACKNOWLEDGMENTS
The authors thank Mr L. Shirvani and Mr G. Yousefi for their
technical assistance and Dr N. Tanideh, Dr M. Hashemnia, and
Dr A.R. Hamidi for providing the facilities.
REFERENCES
1. Oryan A, Khalafinezad A, Toloo N, et al. Effects of 4-chloro-2,6Ybis
(2-hydroxyl-benzyl) phenol on healing of skin wounds and growth of bacteria.
J Vet Med A Physiol Pathol Clin Med 2007;54:585Y591.
2. Oryan A, Zaker R. Effects of topical application of honey on cutaneous wound
healing in rabbits. Zentralbl Veterinarmed A. 1998;45:181Y188.
3. Kondo T, Ishida Y. Molecular pathology of wound healing. Forensic Sci Int.
2010;203:93Y98.
4. Monaco JAL, Lawrence T. Acute wound healing: an overview. Clin Plast Surg
2003;30:1Y12.
* 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Topical application of Aloe vera
A. vera, 25 mg A. vera, 50 mg Normal
37.96 (3.20) 46.76 (14.58) 77.90 (17.72)
28.89 (4.49) 29.17 (1.64) 22.91 (1.42)
23 (4.47) 20.85 (3.89) 17.95 (2.16)
31.76 (3.35) 31.92 (11.14) 61.68 (14.60)
1.82 (0.05) 2.30 (0.65) 3.79 (0.75)
0.064 (0.01) 0.079 (0.022) 0.16 (0.029)
5. Eshun K, Qian H. Aloe vera: a valuable ingredient for the food, pharmaceutical
and cosmetic industriesVa review. Crit Rev Food Sci Nutr. 2004;44:91Y96.
6. Chithra P, Sajithlal G, Chandrakasan G. Influence of Aloe vera on collagen
characteristics in healing dermal wounds in rats. Mol Cell Biochem. 1998;181:
71Y76.
7. Jia Y, Zhao G, Jia J. Preliminary evaluation: the effects of Aloe ferox Miller and
Aloe arborescens Miller on wound healing. J Ethnopharmacol 2008;120:
181Y189.
8. Langmead L, Feakins R, Goldthorpe S, et al. Randomized, double blind, pla-
cebo controlled trial of oral aloe vera gel for active ulcerative colitis. Aliment
Pharmacol Ther 2004;19:739Y747.
9. Langmead L, Makins R, Rampton D. Anti-inflammatory effects of aloe vera gel in
human colorectal mucosa in vitro. Aliment Pharmacol Ther 2004;19:521Y527.
10. Maenthaisong R, Chaiyakunapruk N, Niruntraporn S, et al. The efficacy of
aloe vera used for burn wound healing: a systematic review. Burns. 2007;33:
713Y718.
11. Tai-Nin Chow J, Williamson DA, Yates KM, et al. Chemical characterization of
the immunomodulating polysaccharide of Aloe vera L. Carbohydr Res.
2005;340:1131Y1142.
12. Vijayalakshmia D, Dhandapanib R, Jayavenia S, et al. In vitro anti inflam-
matory activity of Aloe vera by down regulation of MMP-9 in peripheral blood
mononuclear cells. J Ethnopharmacol 2012;141:542Y546.
13. Zhang L, Tizard IR. Activation of a mouse macrophage cell line by acemannan:
the major carbohydrate fraction from Aloe vera gel. Immunopharmacology.
1996;35:119Y128.
14. Im SA, Oh ST, Song S, et al. Identification of optimal molecular size of
modified Aloe polysaccharides with maximum immunomodulatory activity.
Int Immunopharmacol. 2005;5:271Y279.
15. Chithra P, Sajithlal G, Chandrakasan G. Influence of Aloe vera on collagen
turnover in healing of dermal wounds in rats. Indian J Exp Biol. 1998;36:896.
16. Boudreau MD, Fredrick AB. An evaluation of the biological and toxicological
properties of Aloe barbadensis (Miller), Aloe vera. J Environ Sci Health C
Environ Carcinog Ecotoxicol Rev. 2006;24:103Y154.
17. Esua MF, Rauwald JW. Novel bioactive maloyl glucans from Aloe vera gel:
isolation, structure elucidation and in vitro bioassays. Carbohydr Res. 2006;341:
355Y364.
18. Ramamoorthy L, Kemp MC, Tizard IR. Acemannan, a beta-(1, 4)-acetylated
mannan, induces nitric oxide production in macrophage cell line RAW 264.7.
Mol Pharmacol. 1996;50:878Y884.
19. Talmadge J, Chavez J, Jacobs L, et al. Fractionation of Aloe vera L. inner gel,
purification and molecular profiling of activity. Int Immunopharmacol.
2004;4:1757Y1773.
20. Kima J, Leea IS, Parkb S, et al. Effects of Scutellariae radix and Aloe vera gel
extracts on immunoglobulin E and cytokine levels in atopic dermatitis NC/Nga
mice. J Ethnopharmacol. 2010;132:529Y532.
21. Marshall G, Druck J. In vitro stimulation of NK activity by acemannan (ACM).
J Immunol. 1993;150:1381.
22. Pugh N, Ross SA, ElSohly MA, et al. Characterization of Aloeride, a new high-
molecular-weight polysaccharide from Aloe vera with potent immunostimulatory
activity. J Agric Food Chem. 2001;49:1030Y1034.
23. Vázquez B, Avila G, Segura D, et al. Antiinflammatory activity of extracts from
Aloe vera gel. J Ethnopharmacol. 1996;55:69Y75.
24. Womble D, Helderman J. The impact of acemannan on the generation and
function of cytotoxic T-lymphocytes. Immunopharmacol Immunotoxicol. 1992;14:
63Y77.
www.annalsplasticsurgery.com 45
Oryan et al
25. Marshall G, Gibbons A, Parnell L. Human cytokines induced by acemannan.
J Agric Food Chem. 1993;91:295.
26. Oryan A, Tabatabaeinaeini A, Nikahval B, et al. Effects of aqueous extract of
Aloe vera on experimental cutaneous wound healing in rat. Vet Arh. 2010;80:
509Y522.
27. Chithra P, Sajithlal G, Chandrakasan G. Influence of Aloe vera on the
glycosaminoglycans in the matrix of healing dermal wounds in rats.
J Ethnopharmacol. 1998;59:179Y186.
28. Li J, Chen J, Kirsner R. Pathophysiology of acute wound healing. Clin
Dermatol. 2007;25:9Y18.
29. Moon EJ, Lee YM, Lee OH, et al. A novel angiogenic factor derived from Aloe
vera gel: beta-sitosterol, a plant sterol. Angiogenesis. 1999;3:117Y123.
30. Gallagher J, Gray M. Is aloe vera effective for healing chronic wounds?
J Wound Ostomy Continence Nurs. 2003;30:68Y71.
31. Kaufman T, Kalderon N, Ullmann Y, et al. Aloe vera gel hindered wound
healing of experimental second-degree burns: a quantitative controlled study.
J Burn Care Rehabil. 1988;9:156Y189.
32. Schmidt JM, Greenspoon JS. Aloe vera dermal wound gel is associated with a
delay in wound healing. Obstet Gynecol. 1991;78:115Y117.
33. Oryan A, Tabatabaei-Naieni A, Moshiri A, et al. Modulation of cutaneous
wound healing by silymarin in rats. J Wound Care. 2012;21:457Y464.
46 www.annalsplasticsurgery.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery & Volume 77, Number 1, July 2016
34. Tabandeh MR, Oryan A, Mohammadalipour A. Polysaccharides of Aloe vera
induce MMP-3 and TIMP-2 gene expression during the skin wound repair of
rat. Int J Biol Macromol. 2014;65C:424Y430.
35. Oryan A, Moshiri A, Meimandiparizi AH. Effects of sodium-hyaluronate and
glucosamine-chondroitin sulfate on remodeling stage of tenotomized superfi-
cial digital flexor tendon in rabbits: a clinical, histopathological, ultrastruc-
tural, and biomechanical study. Connect Tissue Res. 2011;52:329Y339.
36. Oryan A, Silver IA, Goodship AE. Effects of a serotonin S2-receptor blocker
on healing of acute and chronic tendon injuries. J Invest Surg. 2009;22:
246Y255.
37. Switzer BR, Summer GK. Improved method for hydroxyproline analysis in
tissue hydrolyzates. Anal Biochem. 1971;39:487.
38. Neuman RE, Logan MA. The determination of collagen and elastin in tissues.
J Biol Chem. 1950;186:549Y556.
39. Reissig JL, Strominger JL, Leloir LF. A modified colorimetric method for the
estimation of N-acetylamino sugars. J Biol Chem. 1955;217:959Y966.
40. Lee MJ, Yoon SH, Lee SK, et al. In vivo angiogenic activity of dichloromethane
extracts of Aloe vera gel. Arch Pharm Res. 1995;18:332Y335.
41. Enoch S, Leaper DJ. Basic science of wound healing. Surgery. 2008;26:31Y37.
42. Oryan A, Mohammadalipour A, Moshiri A, et al. Avocado/soybean un-
saponifiables: a novel regulator of cutaneous wound healing, modelling and
remodelling. Int Wound J. 2015;12:674Y685.
* 2014 Wolters Kluwer Health, Inc. All rights reserved.