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Ep.53: “The Unhappy Patient” with Mark Constantian, MD


“The Unhappy Patient” with Mark Constantian, MD

Dr. Mark Constantian, author of “Childhood Abuse, Body Shame, and Addictive Plastic Surgery: The face of Trauma”, shares with us the factors leading to body dysmorphia and how to recognize this condition in unhappy patients.

He’s former president of The Rhinoplasty Society, NESPRS and NESPS, as well as former ASPS board member.

Dr. Constantian’s Website

Catherine’s FREE Book

FREE Advice Call with Catherine

Transcript:

Beauty and the Biz

Ep.53: “The Unhappy Patient” with Mark Constantian, MD

 

Catherine Maley, MBA 

Hello and welcome to Beauty and the Biz where we talk about the business and marketing side of the cosmetic practice. I’m your host, Catherine Maley, author of your aesthetic practice what your patients are saying, as well as consultant to cosmetic practices to get them more patients and more profits. And today’s episode is really special because my guest His name is Dr. Mark Constantian, and he is a closed rhinoplasty specialist and plastic reconstructive surgeon in Nashua, New Hampshire. And he’s been in practice for more than 40 years. As a matter of fact, he’s a native of Massachusetts and both his father and grandfather practice medicine. Now Dr. Constantian teaches regularly at plastic surgery meetings all over the world. And he’s past president of the New England Society of Plastic and Reconstructive surgeons in the northeastern Society of Plastic Surgeons and the rhinoplasty society. Now he’s also a past member of the board of directors of the American Society of Plastic Surgeons, and he’s been an assistant editor of the International Journal of plastic and reconstructive surgery. He’s assistant clinical professor of surgery of that as Plastic Surgery at the University of Wisconsin Medical Center. Now he offers educational books and videos on his innovative rhinoplasty techniques. And the reason I invited him on as a guest is because I read an article where he was being interviewed because he had authored a book in 2019, called child abuse, body shame and addictive plastic surgery, colon the face of trauma. And I thought, wow, that really caught my eye because for all sorts of reasons. So, I want to welcome Dr. Constantian on the show Beauty and the Biz.

Mark Constantian, MD 

Thank you very much for having me.

Catherine Maley, MBA 

You are so welcome. And you know what I just want to open it up with how did this book come about for you and what possessed you to research it and write about it.

Mark Constantian, MD 

I don’t like things that I don’t understand. And the usual experience of most plastic surgeons is to have a patient come in with a problem. you operate patients happy they go away happy. That’s the main whether it’s reconstruction for cosmetic surgery. But I had some patients in the early 90s, who had been in practice maybe a dozen years at the time, whom came almost quickly in succession. And then more than solid it over the next few years who all had good results. Very good results. I could use them as teaching cases in my courses. And yet they were visibly unhappy. One was a university professor who quit her job, because she said she looks so bizarre, she couldn’t appear in public, she only would shop in distant city, she would only go out at night. And what was another woman who was a physician’s wife, who made new who became a recluse in her home. And one was a man who tried to cut off his nose with a razor because he was so unhappy with the way things looked. And I mean, he didn’t, he didn’t do any real damage. But the point was, these were all results that were not only good, surgical examples, but they accomplished exactly what the patient told me that he or she wanted. And I couldn’t understand this. So, I began to go into the mental health literature. And at that time, what I was reading about was a new phenomenon that only was described in the mental health literature in 1987. But now everybody talks about it, which is body dysmorphic disorder, or body dysmorphia. And the first criterion of that problem was supposed to be a defect that was so minor, only the patient could see it or it was something imaginary that no one else could see. And yet the patient got very upset, and his or her life was disrupted. And after that his self-esteem went down. And they had trouble in their families and some of them developed social anxiety disorder or obsessive-compulsive disorder or depression. They became housebound, the worst ones committed suicide. So, there was a lot written about these patients and describing what they look like. But nobody came up with an explanation for why this happened. And that’s what always bothered me, why do people get like this, and there still is really no explanation. They look for genetic characteristics and found them I’m talking about very good mental health researchers. They look for neurotransmitter abnormalities in the brain. They haven’t found those they have found a familial occurrence. anywhere from five to 20% of people who have body dysmorphic disorder, will also have someone in the family with it. And so, this all percolated in my brain as I began to see, see more patients occasionally like this because my practice, although was originally very broadly, plastic surgery, because when I came to New Hampshire in the late 70s, there was nobody in the whole state, whole southern half of the state except me doing plastic surgery, I wanted to go to an unserved area. And so, I did, I did everything but as time went on, I got more interested in complicated nasal surgery and began writing about the teaching about it and people began to associate me with that problem. So, and the practice got more concentrated in that I began to see more of these patients. And that’s partly because across all cultures around the world, the noses the most commonly affected body part, the most commonly obsessed about body part and body dysmorphic disorder. And so, it was natural for me to see more of these patients than people who did say hand surgery. But I still would see people who ought to have been happy with what I did, who I thought seemed perfectly normal ahead of time, and yet were very unhappy and either hated themselves or hated me afterwards, and I couldn’t figure it out. And then I had a man come in to see me once, who said, I had body dysmorphic disorder, but I’m all better now. And I thought, so I liked the man very much. I said to him, if you get a note from your therapist, that you’re stable enough to go through surgery, I’ll operate on you. And he did. And I operated on him very nice man. We got along well; I still have contact with him. That was 20 years ago. And I said to him afterwards, if I write you a letter with a list of questions about body dysmorphic disorder, what do you answer them for me, because I never met anybody. No surgeons ever meet anybody like you, who’s all better? They meet people in the disease? And he said, Sure. So, I sent him a bunch of questions. What’s it like to feel like it inside of other people recognize what you’re going through? Did you meet other people like this at the doctors treat you and so on. And he sent me back a four-page, single spaced letter about his life, which was filled with childhood abuse and neglect, a very turbulent life. an abusive stepfather who had when he was seven years old, I made him submit two photographs. So, the stepfather could show them in the pictures, what was wrong with his nose. Imagine doing that to a child, now regret most of the letter in my book. And by the time he was in high school, he was totally obsessed by this. And then he, he had surgery, and he got even worse, and he had more surgery on his nose, and he got even worse. And then someone started putting him on medications. And then he ended up on a ventilator. So common now with the virus out there, the ventilator, because he had an idiosyncratic reaction to one of the medications. And he ended up finally in a halfway house for schizophrenia. And he and there’s a sentence in the letter saying, I suddenly realized that my problem was not my nose. My problem was that I was 30 years old. I never finished school and never had a job. I didn’t have a girlfriend. And I was going to live in places like this forever, unless I did something about it. Now, that’s a fantastic epiphany and most patients, it’s almost unique. I think, in my experience in BDD patients, most of them never, very rarely have that, that epiphany. So, I thought, all right, at least in one person, here’s an explanation for why people become obsessive about themselves and why they’re so filled with shame. And then I began to read more of the mental health literature and more of the childhood development literature and more of the body image literature and the PTSD literature in the body shame literature. And I ended up reading through this book, there’s something like 830 references in it. Because not because I was trying to turn the tables over in mental health, but because I just wanted to understand this problem. And what I, one of the things I discovered was there were a lot of clues in the literature, but they were scattered. And just like in plastic surgery, people read their own little silo of interest. But I was reading the whole breadth of mental health because anything that seemed relevant, I would read about it in depth. And I began realizing that the people in the body image literature, were asking questions that the people in the childhood development literature could answer, but they didn’t talk to each other. So, I began trying to put this together. And then I wrote two papers that came out in 2014 Plastic and Reconstructive Surgery called why some patients are unhappy. And I had looked at 100 consecutive rhinoplasty patient’s revision rhinoplasty patients of mine, because I noticed one other interesting thing, and that was, when I saw new patients or patients called up and said, I need to have had nasal surgery, I want another one from the doctor. My staff would say bring in a photograph of what you look like before you had surgery, because I thought it would educate me. And I’d be able to explain to the patient how the deformities developed. And often these patients would bring those that look totally normal. No bump. No crookedness, no airway problems. And I’m looking at the picture, say to the patient, what were you trying to accomplish when you had the surgery? Why did you have the surgery? And I say things like, because my mother said I was the ugliest baby she ever saw. Or because my sister was much prettier than I was, or because my father said, how come you’re not as good an athlete as your brother? Or as one man said to me, I had surgery so people would love me. And I thought, okay, there’s something going on here that originally that had nothing to do with the problem. So, I wrote about these patients, these 100 groups of 100 patients, 50 of whom were like this, they originally had totally normal noses. And 50 of them originally had deformities, and there were big differences between them. The people who originally had deformities, USA has several operations were very easy to please. They were very easy on the staff. They weren’t demanding or depressed, right much more pleasant, much more likely to be happy with what I did. The ones who originally had normal noses had more operations, more other cosmetic operations, had started surgery at a younger age, were much more likely to be unhappy with what I did and want another operation or revision, another revision. And so, I began my point in these papers was, there’s a difference between people who start off with no problem, if you will have no medical indication for surgery, they’re driven by something else. And that’s why you can’t make them happy. And I thought those papers would set the world on fire. And I don’t know if anybody ever read them except me. So, but I kept, I kept working on and reading the literature more and then I thought I came across the adverse childhood experiences study. Are you familiar with that?

Catherine Maley, MBA 

I am not but I sure have studied childhood. Yeah, I’m still trying to [inaudible 10:42] too. So, I’m very interested in this topic. And I’ve studied it a lot.

Mark Constantian, MD 

Because a lot of your listeners can pick it all up on the internet, they can’t just go to ace, they have to go do adverse childhood experiences because as you’ll get high blood pressure medication instead of ACE inhibitors. But if they look for Adverse Childhood Experiences study, it was started in the mid-90s, in California at Kaiser Permanente, which, you know, was a good insurance company, and kind of a long story. But the point was they mid-90s essayed 17,000 of their patients present for 10 common kinds of childhood abuse or neglect, emotional abuse, you’re stupid, you’re ugly, you’re never going to amount to anything. Emotional neglect, nobody paying any attention to you. Physical abuse, physical neglect, where you don’t have enough to eat or where sexual abuse, violence against the mother, divorce, alcoholism, mental illness in the family, imprisonment, suicide, I think those are the 10. And they discovered to their amazement, even though this is not a disadvantaged population, middle class, 80%, white, 10%, Asian 10%, black, all employed with good health insurance, that’s 64% of the patients had at least one of those answers. And they were amazed. So, as I when I read the study, I thought this list can’t be true in my patients. I’ve got at this point an elective Aesthetic Surgery practice. Excuse me?

Catherine Maley, MBA 

What’s the ratio between male and female?

Mark Constantian, MD 

In that group, they’re made of 50:50.

Catherine Maley, MBA 

Okay.

Mark Constantian, MD 

Yep. And because they have everybody on a computer system, Ella, the health issues are computerized, they discovered two things from this study in 17,000 people, one was that adverse childhood experiences are very common. Second, the more adverse childhood experiences you have the more health problems you have as an adult, not just depression, and not being able to hold a job. But then unwanted pregnancies, maybe your drug abuse, but heart disease, high blood pressure, cancer, multiple sclerosis, lung disease, asthma, all different kinds of health problems are most of the common adult health problems, had a direct correlation with how many AC aces you had adverse childhood experiences. So, I thought, I think I’ll do this in my patients. So, what I’ve covered in this book was the beginning of that research, probably three quarters of it. And what I’m just wrote up now to publish in the medical literature in our journal was the whole study, which is 218, post-operative patients of mine. And I did post-operative patients for two reasons. One, these questions are too personal to ask somebody in my waiting room was coming to see me about surgery. Why should they tell me the truth? Not only are they too personal, but I don’t want patients to lie? Because they’re afraid if they give an answer, I will reject them for surgery. So, I didn’t, I didn’t say any preoperative patients. I said, only people that knew me that had gone through the surgery that are recovered, that were at least three months after surgery. And I also wanted to be able to put the results in perspective. What were the patients like? How much stress did they put on the staff? how depressed were they? And what kind of health problems did they have? How easy were they to manage? And how happy were they with what I did. And I also tested them for body shame, which is, as I read in the literature, the communist kind of childhood abuse, excuse me, the communist kind of shame that results from childhood abuse or neglect, his body shame, all kinds of all those experiences that create a feeling of shame and the child So, is going through these adverse experiences, tries to understand them, and will explain them to himself or herself, to make it logical. I mean, I got beaten but I must independence very good child. My parents got divorced, but it was my fault. they criticize me all the time, but I’m just a screw up. So, this is the way three and four or five- and six-year-old child will help make sense of his or her world and they learn to cope with it by being perfectionistic by disappearing and being below the radar so they don’t get into trouble whatever they have to do to cope with this crazy environment. And so, shame is the common final pathway, if you will of all kinds of childhood abuse and neglect. And there are three kinds of shame in the mental health literature characterological shame, the kind of person I am. Behavioral shame the way I act, and body shame the way I look. So, if body shame is you interpret the way you feel about yourself. I’m defective. And I know what it is, it’s the way I look. And then of course, the pathway to plastic surgery is pretty obvious. And so, I thought, this is fantastic. This is like the missing piece. So, when I read that in the mental health literature, the body shame component of what’s called the experience of shame scale, which is a recognized metric in the mental health literature. And it asks for kinds of simple questions. Are you embarrassed? By the way you look? Do you like not looking at yourself in the mirror? Do you try to camouflage your appearance? Do you worry about what other people think of your appearance? Those kinds of things, everything related to embarrassment and feeling defective, because of the way you look. So, I collected all this information. And my patients in my practice now is about three quarters women because more common cosmetic surgery, and it’s about 80% cosmetic surgery and 20% reconstructive which is largely skin cancers and a few other things hand surgery. And so, it’s not a broad-based plastic surgery practice. But I still separated the patients into groups the reconstructive ones, the non-rhinoplasty cosmetic patients like the facelift and eyelid patients. The primary rhinoplasty patients who’ve never had surgery before, and the revision rhinoplasty patients who had prior surgery. And what I discovered was overall in my patient population, the prevalence wasn’t 64% like it was in the Kaiser Medical Group, it was 80%. Now this is the first time anybody has essayed childhood abuse experiences in a in a surgical population of any kind. As far as I know, I never in plastic surgery, always it’s been a pediatric or general medical population. And the reconstructive patients almost exactly matched the Kaiser group because they were a basically a general medical group, when it comes in with skin cancers, and they need some sort of wound clothes because dermatologist had removed the skin cancer. So, they’re not their percentages of each type of abuse and neglect almost to the number match the Kaiser numbers, but they were still fairly high. kneeling, emotional abuse was about 40%. And physical abuse was about 25%. And sexual abuse was about 25%. And if somebody asked me, how often do you think these things happen in your patients, I would never have guessed numbers like that.

Catherine Maley, MBA 

There’s a woman named Brittany Brown, and she does TED talk on shame.

Mark Constantian, MD 

Yes, I know her work.

Catherine Maley, MBA 

Yeah, whoever hasn’t watched, it should probably watch it, it turns out, we all have shame. And it doesn’t have to be all of the ACE kind of things. It can be as easy as when you were a little kid, and you’re asking for things. And your parents say you’re so ungrateful, you know, like, I mean, it’s, it’s crazy what the numbers are, and how much all of this has affected all of us.

Mark Constantian, MD 

That’s right. I’ve got four of these myself. Right. So, it is very common. But these experiences don’t affect everyone equally. But and in fact, the we’re hardwired to withstand major traumas, you know, your house burning down or a bad accident or a sudden illness or robbery. It’s the it’s the, what they call the small t instead of capital T trauma in the mental health literature, the column, the constant drumbeat of being insulted by your parents, or put down that can go on all day long. And it’s very disruptive to children. And the problem is, and what many patients get defensive about is that it can be totally unconscious on the parent’s part. If someone had said to my parents that what they did was either neglectful or abusive to their children, they would have no idea what the person was talking about, they’d say, we were just trying to raise two good Christian children who weren’t full of themselves, but they didn’t recognize the effect of their behavior. So, it’s often with good intentions even. But it has an effect the parents don’t realize. And you know, we all we all parent, the way we were parented, we make the same mistakes unless we recognize them and try to change them. So, in conclusion, what I found it all of these patients was not only that, abuse and neglect were common in plastic surgery patients. They were there were four areas where they were much more common than in general medical with emotional abuse, emotional neglect, drug abuse in the family or mental illness in the family. And shame, as it turns out, is the big divider between patients who are happy and patients who were unhappy. When I looked at patients, for example, the revision rhinoplasty patients that had normal noses, the ones that I thought were special trouble when I wrote that first paper six years ago, they didn’t look any different than the revision rhinoplasty patients that started off with deformities, meaning the demographics were all the same. They were just as likely to be perfectionistic or depressed at the same amount of health problems be just as likely to be happy or unhappy after surgery. There were really no differences between them. It’s when I separated the patients, all the patients all 218 patients. into whether they were body shamed, expressed body shame or didn’t express body shame that the numbers totally sorted out differently. The body shamed patients were much twice as likely to be single, much more likely to be depressed, much more likely to So, call themselves perfectionistic. And much more likely to have a history of recreational drug use or drug abuse much more likely to be on antidepressants. their childhood trauma score was much higher. And they were much more likely to be unhappy with the surgery that I did. Meaning when I operated on them, and they wanted another operation, they right away started picking up flaws. It wasn’t good enough it had to it had to be done against something else had to be done. So, I think that right now, Body Dysmorphic Disorder, which these characteristics describe patients who are unhappy after surgery, and often not very healthy, and often have frequently drug abuse problems and add patients. The thing that distinguishes them is not how big the defect is. And you can have a real problem and real medical problem or surgical problem and still be body dysmorphic, it’s whether you feel shame about it or not.

Catherine Maley, MBA 

And then what is social media have to do with your learnings? Because I don’t know what your demographic is. But did you also look at the age of the patients that have these issues?

Mark Constantian, MD 

Yes, well, I mean, they’re not mostly teenagers, that the average age was in the 40s. But it varied. I mean, they reconstructive patients, of course, they’re going to be older because they’re old enough to get skin cancers. But in general, the ages went from the mean age of anywhere from 35 to 60. They’re all miski-middle aged patients. They’re not teenagers.

Catherine Maley, MBA 

Do you think that’s gonna change, though, because of what’s going on with social media and women comparing themselves to the filter images? And Instagram models looking for attention?

Mark Constantian, MD 

I’m not sure, I think all those criticisms have to fall on fertile ground. in mental health, they call that boundaries, you know, there are verbal boundaries, there are physical boundaries, there are sexual boundaries. So, if I have a good verbal boundary, then if someone says something insulting to me, or it says anything to me, it doesn’t have to go in like a hot knife, I can stop that information and decide, is it true? Or should I ignore it, it also contains me so I don’t rage and criticize and gossip to other people. So, if you have a sense, if a person has a sense, even a teenager, I’m precious, I have value, my parents love me, I know I have self-worth. And it’s not something that has to be earned. And it’s not something that anybody can take away. And someone says something unflattering to them, or they see someone else who’s different. And they may say, Well, you know, she’s got better hair than I do. But they will therefore proceed to say, and therefore I’m inferior, I’m not as valuable because I don’t look like that person, or I don’t meet the I was criticized by somebody on social media. So, it doesn’t, it can be out there. But it doesn’t have to go in. See what I mean?

Catherine Maley, MBA 

Although the younger generation, I just have a 13-year-old niece, and she’s watching the influencers on social. And some of them have had way too much work done already in their early 20s. And by that I so I don’t know, what you’re saying is you better have a good foundation to deal with, I guess, social media, because they come at us. So, you better be able to–

Mark Constantian, MD 

I mean not just social media, but life in general. And you know, a lot of the A lot of people in the media and entertainment rather that. I mean, probably that’s an artificial medium, because they need to be flawless. But and they’re extremely harsh on themselves. So, the fact that because their appearance as part of their livelihood, they have to pay much more attention, and they’re much more likely to go ahead and have procedures done earlier than regular people would. It’s like an athlete is going to work out. And what the athlete is going to work out much more than I would. So, there are individual differences. You can’t match yourself to what some young movie star is doing. And say, Well, it’s because she did this, I better be doing it because I’m the same age. But also, it has a lot to do with So, personal integrity. Rene Brown, and her work is very good. I’m familiar with it. I think to me, there’s a critical difference in plastic surgery patients is a difference between being dissatisfied with something and being ashamed of it. If I’m dissatisfied with some physical feature of mine, I know I still have value. I just don’t like the way this sort of this looks. A woman says, I had a good figure before I had children and now, I don’t think that that can be dissatisfaction but it doesn’t demean her in her own eyes as being less valuable now, so she can have a mommy makeover surgery and Come out of it and be happy and go on with her life. And her self-esteem was good before and it’s good after. It’s the person who feels diminished worthless by whatever behavior, appearance, anything that that has a motivation that can’t be fixed by surgery. So, one of the things I tried to say to surgeons is, not every unhappy post-operative patient is body dysmorphic. The unhappiness after surgery is not what characterizes a distorted body image, it’s what precedes the surgery to begin with. If it’s shame versus dissatisfaction, then it’s not really a surgical problem. And that’s why most BDD patients are never satisfied after surgery.

Catherine Maley, MBA 

But the way you do it, you’re interviewing them or giving that assessment questionnaire afterwards and postdocs, [inaudible 25:48] touching it if you’re not– How’re you catching it then if you’re not asking them up front?

Mark Constantian, MD 

Well, one of the things I might say in my book is that you can’t use that survey. Even if patients would give you honest answers, you can’t use the adverse childhood experiences survey as a preoperative screen. Because people can go through childhood trauma and because they’re resilient, they still are affected by it, and they still become functional adults. And I discovered that I couldn’t predict what someone’s a score was going to be, even though I operated on them, and knew them pretty well. You know, the some of the most wonderful, pleasant, successful, likable, grateful patients I had, would check off eight out of 10 things on the list. And I say to them, how come you want a homeless person to a drug addict. And they all had similar stories, I had an aunt, I had a grandmother, I had a coach, I had a teacher, someone who believed in them outside the family, and became a mentor said you can do this. And they responded to that and they were able to escape. The dysfunctional part of the inner circle that I grew up in the message for doctors is you need to really look for functional adults, you need to in terms in surgical terms, my criteria has always been with a patient, do I see the problem the way the patient sees it? analyze it, you know, if this patient says My nose is hideous, it’s ugly, it’s disgusting. those are those are bad words. One patient said to me, I look like an animal. I mean, that’s really troubling. And I said to her, that’s awfully harsh way to describe yourself, oh, no, I look like an animal she would not give it up. That’s So, not normal language for an adult to seal. That’s a repulsion of the self. That’s So, right, there is a bad sign. Patients who misinterpret or twist what I say, are also not behaving like functional adults. So, if I say to someone, that that obviously bothers you a lot, or it seems like that bothers you a lot. And they say to me, you’re saying I’m a bad person. That’s not what I said. They twisted that metabolize it into an insult, which people who are victims of abuse and neglect often do, everything becomes something that happens to them. They have to be people who assess risks realistically. So that the people who’ve had multiple prior surgeries, and even when they’ve had complications, they go back to the same doctor or other doctors and they have more and more problems. And they still keep going ahead. These aren’t people who take life. They take their own self-care rationally; there they aren’t careful about themselves and not looking after they don’t live their lives in moderation. So, all those kinds of things are important. And it also has to do with just the connection that I have with patients. I call this the face of trauma because there’s a page in there where I have photographs of the eyes of patients that were just non-relational, they look disconnected. They look, they’re often gazing off in the distance. They don’t look at me when I take their photographs, or they close their eyes. So, they look off in the distance. They have this sort of glassy eyed appearance, they call that the 1000-yard stare and the mental health literature, it’s associated usually with chronic trauma. So, you know a person who makes good eye contact, who smiles who laughs appropriately who whom you, the surgeon feels very comfortable and connected with and who the surgeon, he or she can see the patient’s problem in the same way can manage it can manage the patient has a patient that understands that complications do occur and that all of us have them and that they have to be prepared to deal with them, even if they’re uncommon. And the patient is who understands that perfection is not the goal of surgery perfect the goal of surgery is the best possible surgical result. Those are the people that are going to be the good patients because indirectly are testing for a functional adult.

Catherine Maley, MBA 

What do you recommend to the surgeons who have those patients differing in the photos of celebrity?

Mark Constantian, MD 

I don’t mind that actually. A lot of surgeons hate it and I’ve actually encouraged it because I’ve ever felt it got me into trouble. And because I can use it as an educational tool. Now someone who’s got a very broad features and heavy tissues and brings in a photograph Audrey Hepburn, as your audience knows, still knows who that is, I have to say, you know, the difference between her nose and yours is the fundamental differences, your tissues are much heavier, her skin is very thin. So, I can’t make your nose look like that. But you have a bump, I can make it straight, you don’t have an Angular tip, I can make it more contoured. So, it has a better shape, you aren’t symmetrical, I can give you a better symmetry, you don’t have a good airway, I could give you a better airway. So, I try to get to the goals that I can reach that are similar to the ones that patient wants. And reasonable people will accept those unreasonable ones won’t. And that’s a good, that’s a good screen. So, I don’t mind the photographs, if they’re used as educational tools. I’ve never had a patient come back and say, look at the picture I brought you I don’t look like her. But I’m very careful. I you know, I’d only say this. But after I see patients when they book surgery, I write each patient a letter. And I describe exactly what’s in my office notes. I dictated myself, you have these four problems, this is what you told me, this is what we need to do. These are the problems we might have. This is the percent chance that I might need to do a touch up surgery if you want the best result I can provide. And the patient signs that and it goes in the chart. They keep a copy and I keep a copy and that helps.

Catherine Maley, MBA 

Okay. So how did you explain–? I’m sure you must have been asked about Michael Jackson, for example. How does Michael Jackson nose happen?

Mark Constantian, MD 

He’s the poster boy for what I’m talking about. He had a very abusive childhood and a father who was extremely critical. And in fact, you can find a YouTube video that someone sent me of him being interviewed about the way his father said, you didn’t get that nose from me. And the interviewer says to him, how did you feel when your father said that and, and Jackson sort of gazes off in the distance and he said, it made me want to die. That’s emotional abuse. So, here’s a young man who, despite everything was really tormented, and was constantly trying to change his appearance to meet something he had in his head. Each operation was going to make him feel he thought better. But it was never enough. Because the problem had nothing to do with the physical appearance. I’ve had patients like that.

Catherine Maley, MBA 

What a shame. By the way, go back to that patient you had– the male who said I had this disease and now I don’t. Just loop it around. How did he conquer it? What did he do?

Mark Constantian, MD 

He went back to school, he took action. He went back to school; he became a teacher. He became much more relational. Through that he opened up and he became married, I got married, he had children. When I see him, he still struggles. I send him a copy of my book because as the president because he turned me on to so many critical ideas. And with His permission, I put most of his letter in my book. And he said, I am afraid to read it because it might reopen old wounds. I don’t know if I if I so he’s still fragile. I said no, I think I think it’ll empower you if you read it. So, I still don’t know if he’s read it. But so, it wasn’t, he hasn’t transformed into someone different because he had, he had a difficult time. But all self-harming behaviors all shame turns us in toward ourselves. I have a chapter in my book, last chapter, which a lot of the people who’ve read it say is like the desert to the book is all about resilience. and resilience is another one of those things in the literature that people are just, nobody knows why it happens. It just you’re just lucky to have it. You’re resilient. And I don’t believe that’s true. All kinds of self-harming behaviors and addictions turn us in on ourselves. And most addictions are solitary behaviors, they’re not group behavior. And if you’re closed in on yourself, you can’t be resilient. You can’t have the attributes of resilient people. You can’t get support from other people. Because you’re walled off. You can’t have a sense of humor, you can’t have a life perspective, because you’re all closed in ruminating about how miserable you are and how much you don’t like yourself because you’re so ashamed.

Catherine Maley, MBA 

The patients are so myopically focused internally on themselves that you can’t even help them if you try because there’s nothing, they can only hear what’s with their head is telling them versus what anyone else around them is. So Gosh, what Yeah, it sounds like hell.

Mark Constantian, MD 

I went to a bunch of workshops myself because of my own trauma history and helped clue me in to a lot of the ways people around me behaved and helped me with understand my patients certainly myself. Good trauma work is different than a lot of traditional mental health treatment. Because the damage done to a young child is done to the immature brain. It’s not done to the cortical rational brain, which really doesn’t hardly come online to what about six and keeps getting better till we’re in our 20s. So, a child who is very young, even a toddler who is banked if he’s hungry or neglected. If he’s got a wet diaper or ignored us, he cries and learns very early on how he fits in the world. You know whether big people are safe Whether what happens if he’s unhappy whether anybody cares about him. And so, the damage is done to the non-thinking brain to the midbrain. That’s why you go to a cognitive behavior therapy, which is a very common kind isn’t often very good for body dysmorphic disorder, or for a lot of kinds of child inflicted trauma, because you can explain to someone, rationally that what your parents said wasn’t very nice. And what your parents said wasn’t obviously wasn’t true, because you’re a good person, and that the patient will say, Yeah, I get that it all makes sense while they’re in the therapist’s office, but they don’t leave feeling any different. They still feel defective. What trauma work does is it goes back to the childhood experiences, and helps you work through those, and reparent yourself. So that’s, that’s kind of unique therapy. And I think that may be if I’m right about all of this, and I’m right that a lot of body dysmorphic disorder, is the result of shame. And it’s not just something that happens out of the blue, that all the problems in BDD patient existed before they became teenagers, and obsessed. They were all self-esteem issues, and family issues, and depression, and so on. And it all was all before the obsession with the body. It’s just how it manifested. If I’m right about that, then we ought to be able to treat body dysmorphia much better. Because right now, cognitive behavior therapy and antidepressants give about a 50% improvement rate for like a six month follow up. That’s not very impressive. And I think if we, because of my hunches as an outsider to mental health, my hunch is we’re treating at the wrong level.

Catherine Maley, MBA 

Well, I’ve done a lot of study on this myself, and a lot of this happened, you know, from zero to seven years old, so I had to deal with it the rest of your life. There are some modalities by the way, I curiosity, have you ever heard of a plastic surgeon named Dr. Maxwell Maltz. And he developed a program called cybernetics.

Mark Constantian, MD 

He was a plastic surgeon. That’s right. I quote him in my book, as a matter of fact.

Catherine Maley, MBA 

You two could be brothers. He had the same issue. He said, My God, I would give them plastic surgery, and they’re supposed to be happy. And instead, they’re more miserable than when they started. He’s like, What the heck?

Mark Constantian, MD 

No, Mathew Moses was really onto something. And he really understood that you can’t disconnect the problem from the patient. I quote him in the book.

Catherine Maley, MBA 

Yes, I was on probably 24 years old, I was working in corporate. And there were a bunch of us sitting in the office. And this girl was absolutely miserable. She always was, she was a pain in the neck, very miserable, very negative. And she got her nose done with a chin implant, and she comes back, everybody was raving to her how great she looked. And sure enough, I swear to God, the next day, she sounded, I turned around and I said, she sounds exactly what she used to. She was still moaning and groaning and bitching. She was as negative as ever. And I literally said, so what the what was the point of surgery? If you’re still miserable? I, even then I didn’t know what I was talking about that I couldn’t believe that you fix something, and you still were exactly the same person?

Mark Constantian, MD 

Yep, that’s exactly the kind of patient that made me start pulling on this thread.

Catherine Maley, MBA 

Wow, good for you. So back to reality, give me some takeaways for the surgeons like number one, and I already went through, like how they can ID them. But then what do you do when you have an unhappy patient? What Malts do you how do you handle that?

Mark Constantian, MD 

That’s hard. If the patient will do it, I forced myself to see these patients just like I would see anybody else meaning a year, for a year afterwards, some patients won’t come back. But if they will, I listened to them, and I try to give them my best advice, I will operate on them again. And the way I handle that is when they come back, if I know I don’t want to operate on this person, and he or she wants another operation. I when they come to the office, I get photographs right away, I always get them anyway when they come back, but I want to get them before I even talk to them. Because I don’t want them to walk out without me being able to get the document what they look like that gives me a record of how they look the last time I saw them, and then I listen, I often will put the pictures out in front of them and say, show me what you don’t like. And I will I will try to explain if I can, why I think revision isn’t a good idea. There are patients who I think will listen to me and they Okay, okay. And I get the sense that I can I can educate them and they’ll be alright. There are other patients that I know are not happy with that. And I get a sense they’re going to be angry if I say I’m not going to operate on you again. So, what I tell them is, let me think about it. And then they leave. And then I do consider it again. I look at the pictures to make sure I’m not being harsh. And then I write them a letter and I say this is the problem. This is what I see. This is why I think having another surgery is not in your best interest or that you do have an imperfection and I see but because you don’t have confidence in the I don’t think I’m the surgeon to fix it. And I’d be glad to send your records and photographs to anybody you like. And I try to make sure that they have that they have continuity, because I’m not God, I can’t make everybody happy. But I don’t ever say, with some surgeons say, I don’t know how to fix your problem. And I don’t do that with people. My see first patient, you know, the new console that I think shouldn’t have surgery, I don’t say I’m not, I’m not smart enough to handle your problem, or I don’t, I don’t understand your problem. Because that is going to end right away invalidates anything, I’m going to tell them, I do not fix it. But sometimes the cost benefit ratio is not in their best interest. Or sometimes they’re too angry, or too hung up on what the last surgeon did and too bitter, that that’s not the right time for them to go through surgery. And so, I will try to counsel them that way. Because I don’t want them to get into trouble. And that’s a lot of my job as a surgeon is to be an educator.

Catherine Maley, MBA 

Well wait. But then once you’re out, if you’re not saying I’m not the right, surgeon for you, because that’s what I would have said, I would have said, you know what? I don’t think we’re a good fit. I don’t think I can make you happy. Like what do you say other than I don’t want to do surgery on you because–?

Mark Constantian, MD 

In the letter, you mean, I’ll say I don’t think I can make you happy.

Catherine Maley, MBA 

Okay, prefect. Gotcha.

Mark Constantian, MD 

I mean, I just thought this I mean, if a patient has had a very turbulent post-operative course, and it’s finally equilibrated, also say, last time I operate on you, and you were very upset for several months. And I don’t know why that happened, even if I have a sense why it happened. And I don’t think you have to go through that. Again, I think it’s too much stress for you. So, my advice is to leave things as they are, you have a good result and don’t have more surgery. Okay, because I don’t want them to keep shopping because you know, they some the if they look keep looking, they’ll find someone who may not recognize the problem, or may not be able to correct it.

Catherine Maley, MBA 

For sure. Do you ever get calls from other surgeon saying, I just have [inaudible 41:59] in my office and I know you have experience with her or him?

Mark Constantian, MD 

Yes, I do, I get quite a few of those calls. And I give them the same advice I’ve been giving you. And I try to get them to look back at it. Because often there are signs that were the surgeon ignored for one reason or another. And I want them to be able to pick them up next time. frequently. You know, the communist one is a surgeon knowing he or she shouldn’t do the operation. But the patient keeps pressing and pressing and pressing and up. So, I always say don’t do something you don’t believe in. Because the patient doesn’t, the patient is not the surgeon, the patient doesn’t understand the biologic reality, and the likelihood that there’ll be better from going through another operation. And so, you got to be able to feel what you did, you knew for sure was the right thing to do. If they talk you into something, then you have the problem you expected, then you own it. So, I don’t want them to be in that situation.

Catherine Maley, MBA 

Interestingly, I’ve asked many surgeons who have been sued, I said, what did you learn from it? And every one of them has said, I should have listened to my staff. Or they said, I had a feeling that’s right. But I could handle it. And I didn’t want to say no, like, I didn’t want to work with the money.

Mark Constantian, MD 

Those are very, very important points as I never ignore my staff. Because patients will often be on best behavior to me and be obnoxious to the staff and I don’t operate on patients who aren’t good to my staff. That’s always been a rule. But the gut feelings do mean something we have built into us a survival instinct. And there’s a there’s a, an anatomical connection to that it’s one of the vague branches of the facial the vagus nerve. And that’s the, the survival part of the vagus nerve. The dorsal motor nucleus of the Vegas is really a preservative sensation, it’s really mostly below the diaphragm. And if you get that gut feeling that there’s something wrong, it is a biological signal that you shouldn’t ignore.

Catherine Maley, MBA 

I think that takes maturity to finally listen to it. I know it has for me– And my last question is how do you handle negative reviews when you get them, especially online, how are you responding or how are you handling them?

Mark Constantian, MD 

No, I don’t. The reason is, people who write negative reviews, they’re usually they’re so negative. They’re irrational. And if you look at them, that was also posted at 5am or 3am. And these people are– they’re not writing something that a normal balanced person would write. They’re writing something designed to destroy the surgeon’s practice. They’re looking for vengeance. And so, I hope that other people reading the other reviews people write about me if they do that, they’re going to understand reviews that are that bad, probably not balanced reviews. Just like I’ll always go if I’m buying a book online, I always Go to the one-star review. Just even if it’s five- or 505-star reviews, and it’s always something ridiculous. Like, the book came in a dented box, I’m giving it a one star, it’s this kind of thing. It’s like, what is the matter with you? So, I don’t try to do it because you it’s very difficult to answer those reviews. Without divulging information, you can’t do that. You can say if you surgeon feels compelled to, to answer it, it’s always possible to say, I’m sorry, this patient feels like this. We always try to do our best. If she comes back, we’ll try to make it right with her or something benign like that. But I’ve I don’t do that. If they’re one they’re too upsetting to read. Fortunately, there aren’t too many of them. And I just have to count on the other patients that read them to recognize that the good things that people have said in my years of practice, probably count for something.

Catherine Maley, MBA 

For sure. So, this has been fantastic. I really appreciate it. I think the audience will really appreciate it too. And how can they learn more about this topic and you?

Mark Constantian, MD 

Well, I have a website, drconstantian.com. That gives a lot of information about the way I think about my practice if they’re interested in surgical procedures. And they also will find a link to the book there. And the book itself is available from all commercial sellers online.

Catherine Maley, MBA 

All right, and the book is called Childhood Abuse, Body Shame, and Addictive Plastic Surgery: The Face of Trauma. So, thank you so much, Dr. Constantian, for being with us. I really appreciate it.

Mark Constantian, MD 

You’re welcome. It’s been a pleasure.

Catherine Maley, MBA 

All right. So, everybody, I hope you got a lot out of this. If you did, please subscribe to Beauty and the Biz because I would like to spread the word to others who are also interested in building a cosmetic practice. Please give me a five-star review if you feel so inclined. If you’ve got any feedback or other topics or questions, I’d love to hear from you. You can just leave me a message on my website, catherinemaley.com. And then of course, you can always DM me on Instagram at catherinemaley.mba. Thanks so much and we’ll talk again.

Catherine Maley

Catherine Maley

Catherine is a business/marketing consultant to plastic surgeons. She speaks at medical conferences all over the world on practice building, marketing and the business side of plastic surgery. Get a Free Copy of her popular book, Your Aesthetic Practice: What Your Patients Are Saying View Author Profile.

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