Controlled MDA is a technique whereby the skin surface is gradually levigated, layer by layer, until the desired abrasion level is attained, without having unwanted heat effects.

HOW IT WORKS:
The dual action of MDA is clearly demonstrates that a fine cloud of crystals blown at a controlled pressure hits the skin surface and each crystal removes a small fragment. Gradual abrasion to the required depth is attained, a fragment at a time, without unwanted heat effects. The handpiece is, in fact, the probe holder and it is inside this hollow probe that the suction vacuum is created. The used crystals and skin scales are drawn away from the skin and this vacuum causes hyperemia as the superficial skin is "cleaned." The aluminium hydroxide crystals are inert as proved by the fact that there are no records of allergy when using them. The first comparison to be made is with traditional abrasion using a diamond point mill. Epidemic abrasion, which uncovers the superficial layers of the dermis, gently and mechanically erased by the aluminium particles, causes an inflammatory reaction which precedes tissue repair and therefore shows all the well-known inflammatory phases; active hyperemia, appearance of desmocytes, macrophage linfocytes, etc.

CONTROLLED ABRASION:
By abrading only a part, the remaining dermis acts as guiding tissue for the new fibrils which will settle on it in an orderly way, matching the underlying tissue. With this mind, these concepts are more connected to the organism's biological reaction than to the work of the machine, we can begin to understand the application and indications for controlled MDA.

THE ADVANTAGES OF THIS TECHNIQUE:
The advantages of this technique are, above all, in harmony with respect of the biological tissue. The tissues are not ill-treated by a mechanical mill as in traditional microabrasion. This mill often overheats causing burns, whereas, with the controlled MDA method, the very fine powder used gently removes the surface tissues. MDA can be performed to three different depths: superficial epidermic (peeling), superficial dermic (blood oozing), deep dermic (bleeding).

THE INDICATIONS:
The main indications for using controlled MDA is the striae atrophicae, commonly known as "stretch marks." Stretch marks appear when the dermis is lacerated and therefore becomes thin. Stimulation repeated at regular time intervals causes it not only to thicken but also reinforces the lacerated parts, narrowing the underlying "valley" or "cleft." Another important indication is in the treatment of hypertrophic scars where the repaired dermis is in excess and causes the epidermis to protrude: MDA gradually files it down to be flush with the surrounding skin, making the scar considerably less unsightly and noticeable. Following this theory, acne, chickenpox and burn scars and white cheloids can be successfully treated. Also, melasmas and skin pigmentation marks like the so-called "age" marks, considered unsightly especially on ladies' hands), can be erased by controlled MDA. These pigments deposit on the superficial layers of the dermis and only light abrasion at the second level will enable removal and, once the skin has reepithelialized, it will be smooth and blemish-free. Lastly, facial peeling, either in itself or in preparation for the implantation of collagen or autologous collagen, or before plastic surgery (face lifts).

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TABLE 2 INDICATIONS The practitioner or surgeon will be presented with a clean, fresh, fine-grained and well-stimulated complexion which will enable him to achieve better and long-lasting results. In a surgery where aesthetic medicine is practiced, MDA is not only an alternative to other techniques or apparatus: on the contrary, it is complementary, proving how versatile it is. When treating facial aging, the best results are obtained by intermingling more than one type of medical treatment before turning to aesthetic surgery (facial lifting, blepharoplasty, etc). Therefore LASER CO2 treatment, to smooth out wrinkles around the eyes (crow's feet) can be combined with ridolysis of the medium wrinkles, collagen implantation in the deeper lines, myolifting to improve cheek tone and lipolifting for the facial outline and greater depressions.

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All these different techniques, preceded, integrated or followed by MDA are enhanced, therefore better and longer-lasting results are achieved.

METHODS AND TECHNIQUES:
An MDA sitting always begins by thoroughly cleaning the surface to be treated, above all to remove grease before going on to carry out superficial peeling. At this point, and only at this point is anaesthetic (if used) sprayed on because removing the corneal layer allows penetration to a lesser or greater degree into the underlying layers. Ice can be applied to increase the anaethetizing effect: 3 minutes approximately will suffice.

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MOVEMENTS OF THE HANDPIECE:
Movements to be carried out with the handpiece are as follows:
- AXIAL- following the line of the scar
- PERPENDICULAR- perpendicular to said axis
- CIRCULAR -

The combination of these three movements, technically are extremely simple to learn, ensures that superficial abrasion of the skin is very even. If the mechanical system used is fitted with adjustable output and suction pressure, this should be set to requirements. In the course of the sitting, it is very effective to temporarily boist the pressure by pressing the footpedal every 10-15 seconds. This procedure expels waste matter from the lines, increases the flow of abrasive powder, clears the treated area and gives relief to the compressor by bringing the suction pump into action. For example, when treating stretch marks, the nozzle would be run lengthways along the mark until initial hyperemia can be seen and then we would change direction, working across the path originally traced, also stimulating the surrounding skin. We would often finish off the total abrasion. This is followed by cleansing with a physiological solution and the application of a rich moisturizing or antibiotic cream as required.

An application can last from as little as a few minutes up to an hour according to the size of the area to be treated and the abrasion depth. The applications can be repeated at intervals in accordance with the skin's natural repair processes: i.e., usually between 5 and 8 days. (Table 4.) The sittings can be postponed should the patient be unable to attend them due to travel or other commitments and then be taken up again without this being detrimental to the treatment program in any way. The results vary according to the skin type and quality. Fair Saxon-type skins are slower to heal, whereas dark complexions are faster. Stretch marks can be reduced considerably, up to 90%. On dark skins, they can even disappear completely. Fewer applications are required for hypertrophic scars but at longer intervals. Pigmentation marks need fewer sittings but at longer intervals. These are only indications which can be varied to suit patients' requirements without prejudicing the final results. Doctors who have a CO2 LASER will find it very useful to treat the bleeding surface at 15-20 Watt, continuous emission after having cleansed and dabbed the treated part, using the laser at a distance of 80-100 cm, radiating for 3 to 5 seconds at a time until bleeding stops.

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IN SUMMARY:
Regarding Home Treatment... different operators propose various procedures, based on their personal experience. However, the informative principles are very simple and are those concerning the medication of all skin pathologies: cleansing, disinfection and stimulation of biological repair processes. Therefore, once the skin is thoroughly cleansed, it can be covered with antibiotic or moisturizing creams or gauzes with stimulate skin regeneration. In conclusion, this apparatus is easy to use, hardly ever requires anaesthesia, very versatile and suitable for outpatient treatment. The apparatus is extremely safe and does not produce any kind of damage while guaranteeing results. After all, it is not the machine which heals, but the skin itself which is regenerated thanks to biological principles which have been well-known and studied for some time.

In memory of Dr. Arnoldo Cannella - Specialist in Aesthetic and Plastic Surgery