Optimum results with microdermabrasion are obtained after a number of visits - typically four to eight, at the rate of one every 10-14 days. Recent studies indicate that the combination of skin exfoliation and slight vacuum stimulates reproduction by the fibroblasts of new, living cells at the basal layer of the epidermis, in addition to enhanced collagen reproduction. This effect causes cell turnover and improved blood flow. These studies indicate that changes in the skin are appreciable in biopsy slides.
We find that treatment sessions posed sooner than 10 days may reveal that the client/patient's stratum corneum has not rebuilt to an appropriate level to treat progressively at that time, resulting in a more irritated skin, and possibly producing a deeper exfoliation than aesthetic licensing allows.
We strongly believe that the microdermabrasion treatment should be performed in a progressive rather than aggressive manner, to enable accurate monitoring of the client's skill reaction and repair. More progressive treatments are performed when the aesthetician has a full appreciation of the client's progress and individual needs. We also believe that treatment applications on individual clients will, over time, expand and may require more aggressive approaches. In addition, clients who have already undergone a series of four to eight treatments may require higher settings with an increased number of passes to address localized areas of skin imperfection.
In fact, in a Skin & Allergy News (November 1999) article, Dr. M. Sean Freeman in Charlotte, N.C., indicates that more passes at lower vacuum levels create substantially more exfoliation, providing both histology changes and increased visual results without undue discomfort.
A small-scale, machine-based, microdermabrasion study performed by Dr. Bruce Freedman of the Plastic Surgery Associates of Northern Virginia indicated that histological changes indeed occurred, including thickening of the epidermis and dermis, and newly deposited collagen and elastic fibers. Now, those of us who have been performing microdermabrasion treatments since the beginning had observed the topical changes in our clients (and ourselves!). But, this small-scale study gives us irrefutable evidence that what we saw was correct – the modality indeed produces clinical improvement at the dermal and epidermal levels.
In the view of many, microdermabrasion in an aesthetic setting, is designed to be part of a well organized regimen of skin care that includes client education, nutrition, supply of high quality skin care products, and re-education about the dangers of excess exposure to UV radiation. The relationship developed between aestheticians and their clients offers maximum opportunity for this educational process and the introduction of new modalities designed to promote enhanced skin health.

Typical application potential for microdermabrasion includes:

• Sun induced pigmentation
  problems, melasma on the face,
  neck, and décolleté
  
• Reduction of whiteheads and
  blackheads formation due to
  regular exfoliation
  
• Blending of fine lines and minor
  wrinkles
  
• Facilitating ease of sebum and
  comedone extraction
• Reduction of dormant acne scars
  and blemishes
  
• Blending the texture of lazed to
  non-lazed areas after laser skin
  resurfacing
  
• Pre-treatment for cosmetic
  surgery patients
  
• Reduction of well healed, raised
  scars, and calluses
  
• Enhanced application of self
  tanning products

Contraindications
Recognition of contraindications, in addition to each client's clinical end point, is vital. While the procedure can be quite benign, aestheticians must continue to approach the treatment with respect, as things can still go wrong, and common sense should prevail when determining the treatment of any potential client.

Microdermabrasion is generally contraindicated where any of the following conditions exist:

• Active, uncontrolled or brittle
  Diabetes
  
• Raised Moles, Warts, Skin tags
  
• Active Acne or undiagnosed skin
  lesions Viral lesions, Herpes Simplex
  1, Shingles
• Eczema and Seborrheic Dermatitis
  
• Severe Rosacea or Telangectasias
• Tattoos
  
• Oral Blood Thinners (includes
  Coumadin and Aspirin Therapy)
  
• Skin Cancer and Auto Immune
  Diseases
  
• Vitiligo
  
• Sinus infection
• Long-term Prednisone or Cortisone
  users
  
• Sunburned skin

Bridging The Gap
Does microdermabrasion take the place of other types of exfoliation? The answer is no! However, it is an extremely useful tool to enhance what we already do. One must keep in mind that microdermabrasion is simply an excellent tool in the hands of a good aesthetician, not a "philosophy" unto itself. Microdermabrasion has a place in the aesthetic environment to assist the client in improving her skin while eliminating the downtime that is generally attendant to deeper chemical and laser peels.
It has been said that microdermabrasion is a bridge between the aesthetic AHA exfoliation and the deeper chemical peels and laser ablations. It has frequently been found that a single microdermabrasion treatment (consisting of multiple passes at lower vacuum levels) may result in the equivalent of three aesthetic strength AHA exfoliation treatments. However, microdermabrasion is a sequential treatment that works by exfoliating a portion of the dead stratum corneum without gross stimulation of melanocytes that produce either normal or excess pigmentation.

Hand Treatments
Hand treatments can be tricky, as it requires the diligent cooperation of the client between treatments. While the skin on the hands has less adipose tissue residing beneath it, the upper layers of the epidermis on the hands have generally been subjected to much more sun exposure perhaps than the rest of the body, creating significant hyperpigmentation or "liver spots". This means that while the skin may appear tough, it can very easily be damaged, and care must be taken in not using too strong a vacuum pressure when performing this treatment.
The client must understand that in order to reduce the hyperpigmentation, she or he must commit to faithfully using a tyrosinase-inhibitor and applying a strong sunscreen throughout the day, immediately after washing every time. Without this level of commitment from the client, the results may be negligible, at best. The actual hand treatment may be performed while the mask is on the clients' face, providing enhanced efficiency within the allotted treatment time, while retaining the option of charging or not charging for this particular add-on treatment, as the case may be.

Combination Treatments
There are some clinical studies being conducted under medical auspices regarding the use of chemical peels, such as AHAs, BHAs and modified Jessner's, in combination with microdermabrasion.
While some may advocate the use of AHAs, alcohol, or acetone to "prep" the skin for microdermabrasion in order to reduce surface oils, we are not attempting to penetrate a water-based chemical exfoliant such as an AHA or modified Jessner's. Microdermabrasion has no difficulty in removing the numerous layers of the stratum corneum with the technician performing multiple passes. If the purpose of applying a stratum corneum softener such as a salicylic acid product prior to microdermabrasion is to enhance the treatment for oily, thicker or acne-prone skins, then this is an additional step to the protocol. The benefits of this type of pretreatment with salicylic acid includes its anti-inflammatory and antibacterial qualities, as well as its keratolytic properties.
The use of high percentage AHAs prior to treatment may compromise the use of active topical ingredients in the post-treatment protocol, thus inhibiting the best results available.
Additionally, any topical ingredient applied immediately after microdermabrasion will penetrate the layers of the epidermis very rapidly. This includes all chemical peels. When a chemical peel penetrates down through the layers of the epidermis, there is the possibility of causing not only extreme discomfort to the client, but oozing and scabbing as well. When this occurs, you have affected the dermis, creating a significantly deeper exfoliation than aestheticians are licensed to perform, along with the potential of scarring and hypo- and hyperpigmentation.
We must remember that as aestheticians, we are licensed to topically enhance the appearance of the skin. We cannot exfoliate anything beyond the superficial stratum corneum. Applications for microdermabrasion such as removal of stretch marks or tattoos must be deferred to the physician.

Pre- and Post-Operative Applications
Use of microdermabrasion treatments for pre-operative skin conditioning can be an additional marketing tool when promoting your services and networking with esthetic surgeons. Most aesthetic surgeons now acknowledge that prescribed pre-operative skin care treatments can enhance their surgical results, and endorse their use.
While use of microdermabrasion pre- or post-operatively is currently not well documented, we do know that preparing the skin before undergoing facial cosmetic surgery or laser skin resurfacing, may assure clients of decreased healing time, with enhanced surgical results. Additionally, for those clients with AHA sensitivities, but who still need pre-operative skin preparation, microdermabrasion is an ideal modality, providing the exfoliation stimulation necessary for renewed epidermal production without the chemical irritation.
These types of pre-operative treatments may be done every 7-10 days for a period of no longer than four weeks in order to stimulate cell renewal, and it is preferable to recommend that the patient receive at least two to three treatments.
A series of progressive treatments may also be used to help blend the texture of lazed and non-lazed skin on the delicate neck tissue. This type of "neck rejuvenation treatment" would be considered significantly more aggressive than a typical microdermabrasion treatment, with multiple passes (four to six or more) performed at moderate levels to maintain optimal control, and the patient should be advised that they may be quite erythemic for a few days. However, it can provide significant positive results for those patients concerned about the difference in skin texture after laser skin resurfacing. Keep in mind that performing this sort of treatment with multiple passes allows for significant control of exfoliation - a key factor when working on the delicate neck tissue. It is never recommended to perform high-energy/single pass microdermabrasion in any area, but especially not on the neck and/or eyes.
Additionally, if only certain anatomical areas have been resurfaced, such as the peri-orbital or peri-oral regions, microdermabrasion can be used to assist in blending any resultant line of demarcation in these areas.
Of course, any of these pre- and post-surgical treatments must be conducted with the advice and consent of the attending surgeon.
Manual vs. Machine Microdermabrasion Issues
Early reports from 1997 showed that while the professionals using microdermabrasion equipment were experiencing visible results, more often than not the physicians themselves were "pooh-poohing" the whole experience as a "fad" – or worse, "fluff and nonsense." Current reports in medical journals and presentations to medical conferences are showing that machine-based microdermabrasion is not going away, and physicians have hopped onto the bandwagon, with clinical studies now confirming histological changes. A few years ago, a number of innovative entrepreneurs decided to begin a new trend – "manual" microdermabrasion. Using the aluminum oxide crystals in either a cream or gel base massaged onto the skin, or with paddles impregnated with crystals, the major expense was circumvented and many new products were born.
First, let us be clear, "true" microdermabrasion, as the patent states, involves the impact of aluminum oxide crystals onto the skin through the use of a closed-loop vacuum pump, which simultaneously projects the crystal onto the skin while vacuuming up the waste crystal along with the exfoliated skin. "Manual" microdermabrasion should really be called manual crystal exfoliation, as it uses either the hands or other tools, along with the crystals to gently exfoliate the upper layers of the epidermis.
Manual pros and cons
It is clear that while manual microdermabrasion provides an adequate interim at-home treatment, properly performed, it does not have the ability to regenerate collagen, elastin fibers, thicken epidermis, and dermis without the vacuum that the machines provide. Janet McCormick, MS, CIDESCO Diplomate, considers that "manual microdermabrasion is a misnomer, as I feel that it is not a 'replacement' for microdermabrasion, but I do feel it has a definite place in our services - just a different place." James E. Mason, President/Founder of Southwest Esthetic Services, Las Vegas, NV, agrees, adding "I do not believe it replaces MDA, can substitute for it, or give the level of benefits over those that have been demonstrated in clinical practice. It should be used as we use ALL the tools available to us. . .in the right circumstances, with the right clients, and following the right protocol."
The professional must bear in mind that clients using a cream or gel-based manual microdermabrasion product at home, using the hands as the manipulator, can over-exfoliate and cause sensitivity issues, including higher likelihood of sunburn, hyperpigmentation in those with higher level Fitzpatrick skin types, and possible exacerbation of acneic skin. We need to remind both ourselves and our clients of the old adage, "If a little is good, more is better" – and then explain that it isn't necessarily true!

Machine pros and cons vs. Manual Treatments
In addition to an efficient exfoliation method, machine microdermabrasion causes dermal stimulation that occurs when the skin is vacuumed. Mason explains that "there are two primary and distinct benefits from MDA, both related to the effect of deep exfoliation AND vacuum pressure. The first, and most relevant is the initiation of microwounding on the surface of the skin, which causes an inflammatory reaction. Accordingly, the body initiates a healing response, which generates re-epithelialization of the stratum corneum. However, the less obvious, and potentially MORE significant benefit is that the vacuum pressure utilized causes a deeper-acting response whereby collagen growth is stimulated, causing remodeling at the basement membrane, the laying down of new collagen fibers, and structural reintegration."
James Upperman, of Esthetic Services in New Jersey, concurs and says that "this filling of the arterioles and venules is what increases oxygenation and increases cellular turn over and the formation or regeneration of collagen and elastin fibers. This has been understood for years, via vacuum facials. Vacuum also has the ability to cause the epidermis and dermis to thicken." Clinical studies showing histological changes in the epidermis, dermis, and with renewed collagen and elastin fibers support these conjectures.
An additional benefit of machine microdermabrasion, according to Mason, and I wholeheartedly agree, is that removing cornified tissue allows for deeper penetration, diffusion, and uptake of bioactive ingredients and the thinking is that this can improve the effectiveness of topically applied actives. Assuming that moisture levels and appropriate secondary care are considered in the treatment plan, machine microdermabrasion can provide a fresher surface look to the skin on an occasional basis, and potentially reduce or improve the look and function of the skin when provided as a treatment series.

Conclusion
We can all acknowledge the boon to our profession that was born of microdermabrasion. That being said, there are always at least two sides of an issue. While Machine microdermabrasion is extremely effective, used correctly, and can improve many aspects of skin health, there are still downsides to its use. Manual microdermabrasion is not necessarily the "enemy" some of us professionals may have made it out to be, given the proper instruction, client, and situation, it can also fit into our armamentarium.

Licensed in aesthetics in both Arizona and Oregon, Laura Root is a Nationally Certified Surgical Technologist, and CIDESCO Diplomate. She consults with medi-spas in formulating skin care products. Laura's fourth book, The Skin Care Professional's Chemistry and Ingredient Handbook, is now available. Her previous publications include the 7th Ed. of A Complete Guide to Microdermabrasion, Techniques & Protocols for the Medical Skin Care Clinic, and Ultrasound and Electrotherapy, Applications, Techniques & Technology for Medical Aesthetics. For ordering information, Laura may be contacted via e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it. or through www.estheticeducationresource.com