Introduction

Around the world, plastic surgery has gained fame in the last two decades. Plastic and reconstructive surgery is a specialty that deals with the treatment of parental or acquired tissue abnormalities to improve the appearance and function of different parts of the body (1, 2). It is a flexible discipline in which surgeons conduct several various cosmetic and reconstructive procedures (3). Some primary care doctors, nurses, medical students, and the public appear to have very little knowledge of plastic surgery and a bad view of it (4). Plastic surgery is a wide, dynamic, and developing specialty field not limited by anatomy or organ system. Many sub-specialties are available within plastic surgery domain, including breast surgery, hand surgery, pediatric plastic surgery, skin cancer, craniofacial trauma, trauma reconstruction, oncology reconstruction of ophthalmic eye surgery and others (5, 6).

Over the last few years, the number of cosmetic procedures has increased, whether surgical or non-surgical (7). A Recent cross-sectional 2019 study in Saudi Arabia has shown that medical students are not sufficiently aware of plastic surgery (8). One further questionnaire-based study in India in 2017 found that their medical associates misunderstand plastic surgery as a specialty (9). A Survey study was published in 2017, found that the perception among medical students in their study showed a gap in plastic surgery awareness (4). In 2019 research assessing the efficacy of plastic surgery simulation training for undergraduate medical students found that the experience of students Showed an improvement of 19.9% after attending the course (10). Surveys conducted in 2015 among undergraduate medical students showed that 280 students claimed that their medical education did not provide a basic understanding of specific patient problem handled by plastic surgeons (11).

The Kingdom of Saudi Arabia (KSA) ranked 30th in the top 30 countries with the highest levels of cosmetic procedures in the world according to a survey conducted by the International Society of Aesthetic Plastic Surgeons (ISAPS) in 2018 (12). According to the ISAPS, overall procedures are rising by 5.4% relative to 2017 in comparison to 2018 (12). Also, women tend to be exposed to more cosmetic procedures than men, at about 87.4%, comprised to 12.6% in men of all procedures (12).

In 2015 a study was done in King Abdulaziz University (KAU) to assess the experiences and attitudes of female university students towards cosmetic surgery and reported that 2.2% received cosmetic surgery while 11.4% were potential cosmetic surgery candidates (13). In 2018, a study was done in King Khalid University to find out the knowledge of the medical students on plastic surgery and its relationship with their cultural factors. The study found that the perception towards plastic surgery was positive for 45.6% of the participants and 18.4% reported that plastic surgery is a good specialty and 34.9% reported that their biggest concerns about joining to cosmetic surgery is the difficulty to be accepted in this specialty. The study found a significant relationship between plastic surgery and cultural factors and, due to cultural factors, a large proportion of them reject plastic surgeons (14).

A recent study was conducted at Jeddah University to determine the causes of plastic surgery misperceptions among medical students and interns. The study showed that the recommendation from family or friends was the most relevant source of evidence to select plastic surgery and their greatest concern is difficult to consider in the plastic surgery program. The participants selected religious doubt as the view of the plastic surgery community in Saudi Arabia. The study concluded that the curriculum of the medical college should pay more attention to plastic surgery and concentrate on the specialty's non-cosmetic portion (15). To our knowledge, studies assessing the gap of knowledge about plastic surgery among medical students are scarce. Thus, the aim of this study was to assess knowledge and perception of plastic surgery among Medical Students in the Western Region of Saudi Arabia.

Methodology

This is a cross-sectional study which was conducted between January 2021 and July 2021. The study was done through an online survey which was distributed through social media groups among the communities of medical students. We included all male and female undergraduate medical students between third and sixth year of medical schools from the western region of Saudi Arabia. Meanwhile, we excluded first year medical students, second year medical students, interns and incomplete submissions. A pre-designed questionnaire was distributed online that included 25 questions divided into three main domains. The first was participants’ demographics that included age, gender, region, place of residence, university, educational level, academic GPA and nationality. The second domain was to assess their knowledge regarding the specialty of plastic surgery, and their perception about the specialty. That included areas of self- evaluation, interest in rotation, concern, cosmetic impression, the importance of plastic department, the source of information and the financial and risk issues. The third section will contain three case scenarios to assess the knowledge regarding specific plastic surgery procedures. The study was approved by the research ethics committee of the directorate of health affairs. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 25. Qualitative data was expressed as numbers and percentages, and Chi- squared test (χ2) was applied to test the relationship between variables. A p-value of <0.05 was considered as statistically significant.

Results

A total of 387 student answered the survey. Out of them, 65.4% were females, 94.6% were aged 20-25 years, 94.3% were Saudi and 45.7% were from Jeddah region. Around 29.7% from the participants studied at Taif University and 50.4% were in the 6th medical grade (Table 1). Furthermore, most of the students (78.3%) rated their knowledge about plastic surgery as “little” and 11.1% took a plastic surgery rotation. Regarding the respondent’s knowledge regarding conditions treated by plastic surgery, burns were the most commonly reported conditions chosen that are treated by plastic surgery (71.1%).

Table 1. Distribution of studied students according to their characters, college, academic year and GPA (N=387)
Variable	No. (%)
Gender
Female Male	253 (65.4%) 134 (34.6%)
Age
<20 20 – 25 26 – 30 > 30	7 (1.8%) 366 (94.6%) 13 (3.4%) 1 (0.3%)
Nationality
Non-Saudi Saudi	22 (5.7%) 365 (94.3%)
Place of residence in Western Region
Al Madinah Jeddah Makkah Other Taif	58 (15%) 177 (45.7%) 38(9.8%) 5 (1.3%) 109 (28.2%)
College
Batterjee Medical College Fakeeh College of Medical Sciences Ibn Sina National College Jeddah University King Abdulaziz University King Saud Bin Abdulaziz University Other Taibah University Taif University Umm Al Qura University	5 (1.3%) 25 (5.6%) 89 (23%) 10 (2.6%) 27 (7%) 24 (6.2%) 2 (0.5%) 58 (15%) 115 (29.7%) 32 (8.3%)
Academic year
3rd year 4th year 5th year 6th year	39 (10.1%) 73 (18.9%) 80 (20.7%) 195 (50.4%)
GPA
Out of 4 Out of 5	155 (40.1%) 232 (59.9%)
GPA Grade out of 4
<2 2-2.49 2.5-2.99 3-3.49 3.5-4 4.5-5	4 (1%) 4 (1%) 20 (5.2%) 60 (15.5%) 66 (17.1%) 1 (0.3%)
GPA Grade out of 5
3-3.49 3.5-3.99 4-4.49 4.5-5	10 (2.6%) 39 (10.1%) 89 (23%) 94 (24.3%)

* GPA: grade point average

Meanwhile, the most common source of information regarding plastic surgery was the internet (59.6%) (Table 2). Regarding the relationship students’ gender and academic level, female participants were more likely to know about plastic surgery in comparison to male students (p-value = 0.034). However, there was no significant relationship between gender and academic level and their knowledge level (p-value = 0.384) (Table 3).

Table 2. Distribution of studied students according to their knowledge about plastic surgery (N=387)
Variables	No. (%)
How is your knowledge about plastic surgery?
Excellent Little No knowledge at all	17 (4.4%) 303 (78.3%) 67 (17.3%)
Have you ever taken a plastic surgery rotation?
No Yes	344 (88.9%) 43 (11.1%)
The following conditions are treated by plastic surgery (you can choose more than one)
Burns Rhinoplasty Breast reduction or enhancement surgeries Cleft lip and palate (Congenital) Eyelid tears and cuts over the face Congenital anomalies of ear and nose Abdominoplasty (tummy tuck) Fracture of the jaw and face Finger amputations Bedsores Maxillofacial surgery Injuries to nerve of the hand and legs Colorectal surgery Total knee replacement Glaucoma surgery	275 (71.1%) 256 (66.2%) 265 (68.5%) 237 (61.3%) 214 (55.3%) 202 (52.4%) 184 (47.8%) 170 (44.1%) 87 (22.7%) 54 (14.2%) 53 (13.7%) 43 (11.3%) 31 (8.1%) 4 (1%) 2 (0.5%)
What are the sources of information regarding plastic surgery?
Internet Television Friends Personal encounter Teaching session Clinical rotation Workplace Books Others	230 (59.6%) 174 (45.1%) 138 (35.8%) 82 (21.2%) 54 (14%) 39 (10.3%) 35 (9.1%) 11 (2.8%) 9 (2.3%)

Table 3. Relationship between students’ gender and academic level and their knowledge level about plastic surgery
Variable	How is your knowledge about plastic surgery?			χ2	p-value
	Excellent	Little	No knowledge at all
Gender
Female Male	11 (64.7%) 6 (35.3%)	189 (62.4%) 114 (37.6%)	53 (79.1%) 14 (20.9%)	6.78	0.034*
Academic year
3rd year 4th year 5th year 6th year	2 (5.1%) 2 (2.7%) 3 (3.8%) 10 (5.1%)	31 (79.5%) 53 (72.6%) 60 (75%) 159 (81.5%)	6 (15.4%) 18 (24.7%) 17 (21.3%) 26 (13.3%)	6.35	0.384

* Statistically significant

Most students (61.7%) responded that maxillofacial surgery was the specialty pf choice that should repair jaw fracture and cleft lip. As for the case scenario of the brachial plexus injury, 77.3%, 52.6%, 18.9% and 77.3% replied that the responsible specialties are neurosurgery, orthopedic surgery and plastic surgery, respectively. Most of the participants and replied that the specialties responsible for breast reconstruction are plastic surgery (88.3%) and general surgery (61.7%). However, about 78% of the students stated that specialty of choice to perform surgical tendon repairs is orthopaedic while 55.3% stated it was plastic surgery. More than half (57.8% and 51.4%) replied correctly that the specialties responsible for face lift are plastic surgery and maxillofacial surgery respectively, while only 20.1% reported that it is the otolaryngology specialty. As for the specialty responsible for management of a second degree burn on leg, 51.1% of the participants reported that it is plastic surgery (Table 4).

Table 4. Distribution of studied students according to their response to case scenarios related to plastic surgery (N=387)
Variable	No. (%)
A patient has a broken jaw, what specialties should repair the jaw fracture?
Orthopedic surgery Cardiothoracic surgery Dermatologic surgery Plastic surgery (correct answer) General surgery Pediatric surgery Gynecological surgery Vascular surgery Maxillofacial surgery (correct answer)	238 (61.7%) 89 (23.1%) 6 (1.8%) 218 (56.4%) 176 (45.6%) 10 (2.6%) 1 (0.3%) 3 (0.9%) 280 (72.6%)
A child was born with a cleft lip. which specialties usually does the surgical repair of the cleft lip?
Orthopedic surgery Cardiac surgery Dermatologic surgery Plastic surgery (correct answer) General surgery Pediatric surgery Gynecological surgery Vascular surgery Maxillofacial surgery (correct answer)	91 (23.7%) 1 (0.3%) 2 (0.5%) 198 (51.3%) 130 (33.6%) 24 (6.3%) 15 (3.8%) 103 (26.8%) 173 (44.9%)
Your patient had a significant brachial plexus injury from a motorcycle accident. What specialties treat this type of injury?
Orthopedic surgery (correct answer) Cardiac surgery Dermatologic surgery Plastic surgery (correct answer) General surgery Pediatric surgery Gynecological surgery Vascular surgery Neurosurgery (correct answer)	203 (52.6%) 33 (8.7%) 8 (2.1%) 73 (18.9%) 129 (33.5%) 87 (22.6%) 3 (0.7%) 178 (46.1%) 298 (77.2%)
Friend of yours had one of her breasts removed to which specialties would you refer her to do her breast reconstruction?
Orthopedic surgery Cardiac surgery Dermatologic surgery Plastic surgery (correct answer) General surgery (correct answer) Pediatric surgery Gynecological surgery Vascular surgery	130 (33.7%) 28 (7.4%) 13 (3.5%) 341 (88.3%) 238 (61.7%) 4 (1.2%) 7 (1.8%) 9 (2.3%)
A patient cut one of his hand extensor tendons. What specialties should do the tendon repair?
Orthopedic surgery (correct answer) Cardiac surgery Dermatologic surgery Plastic surgery (correct answer) General surgery Pediatric surgery Gynecological surgery Vascular surgery	304 (78.6%) 11 (6.6%) 16 (4.1%) 214 (55.3%) 146 (37.8%) 45 (11.6%) 0 (0.0%) 66 (17%)
40 years women went to a play clinic reception in order to have a face lift, which of the following specialties usually do the procedure?
Orthopedic surgery Cardiac surgery Dermatologic surgery Plastic surgery (correct answer) ENT (correct answer) Maxillofacial surgery (correct answer) General surgery Pediatric surgery Gynecological surgery Vascular surgery Missing data	23 (5.9%) 16 (4.1%) 4 (1%) 224 (57.8%) 78 (20.1%) 199 (51.4%) 98 (25.3%) 37 (9.5%) 0 (0.0%) 9 (2.3%) 17 (4.4%)
20 years young female came to the ER suffering from a second degree burn on her leg, which specialty should manage this case?
Orthopedic surgery Cardiac surgery Dermatologic surgery Plastic surgery (correct answer) General surgery Pediatric surgery Gynecological surgery Vascular surgery Missing data	19 (4.9%) 7 (1.8%) 94 (24.2%) 198 (51.1%) 153 (39.5%) 11 (2.8%) 0 (0.0%) 38 (9.8%) 17 (4.4%)

Almost half of the respondents (53.2%) reported that plastic surgery is an essential specialty, 34.1% were interested in plastic surgery, and being competitive specialty was the biggest concern about being a plastic surgeon for 38.8% of students. About one third of students (30.5%) thought that plastic surgery and cosmetic surgery are the same and 22.5% reported that plastic surgery procedure is scarless. Only 9.8% of students reported that they think that plastic surgery is expensive and meant for rich and famous and 68.2% reported that plastic and cosmetic surgeries has a risk that is similar as in other surgeries and very risky respectively (Table 5).

Table 5. Perception of studied students about plastic surgery
Variable	No. (%)
What do you think about plastic surgery as a specialty?
Essential Like any other specialty Not ethical Not suitable	206 (53.2%) 167 (43.2%) 6 (1.6%) 8 (2.1%)
Are you interested in plastic surgery?
No Yes	255 (65.9%) 132 (34.1%)
What’s your biggest concern about being a plastic surgeon?
Competitive specialty Ethical and religious issues Getting bored No fears Other	150 (38.8%) 111 (28.7%) 23 (5.9%) 55 (14.2%) 48 (12.4%)
Do you think plastic surgery and cosmetic surgery are the same?
I Don’t know No Yes	99 (25.6%) 170 (43.9%) 118 (30.5%)
Is plastic surgery procedure scarless?
I Don’t know No Yes	134 (43.6%) 166 (42.9%) 87 (22.5%)
Do you think that plastic surgery is expensive and meant for rich and famous?
Yes No I Don’t know	38 (9.8%) 184 (47.5%) 165 (42.6%)
Do you think plastic and cosmetic surgeries are very risky?
Does not involve any risk. I Don’t know The risk is similar as in other surgeries. They are very risky	18 (4.7%) 53 (13.7%) 264 (68.2%) 52 (13.4%)

Regarding the relationship between students’ gender and their perception about plastic surgery, a high number of female students reported that their biggest concern about being a plastic surgeon is being a competitive specialty (P-value = 0.001). Similarly, those who thought that plastic surgery is expensive and is meant for rich and famous was statistically significant when compared to male students (p-value = 0.04) (Table 6).

Table 6. Relationship between students’ gender and their perception about plastic surgery
Variable	Gender		χ2	p-value
	Female No. (%)	Male No. (%)
What do you think about plastic surgery as a specialty?
Essential Like any other specialty Not ethical Not suitable	134 (65%) 109 (65.3%) 4 (66.7%) 6 (75%)	72 (35%) 58 (34.7%) 2 (33.3%) 2 (25%)	0.34	0.952
Are you interested in plastic surgery?
No Yes	172 (67.5%) 81 (61.4%)	83 (32.5%) 51 (38.6%)	1.42	0.233
What’s your biggest concern about being a plastic surgeon?
Competitive specialty Ethical and religious issues Getting bored No fears Other	80 (53.3) 86 (77.5) 15 (65.2) 35 (63.6) 37 (77.1)	70 (46.7) 25 (22.5) 8 (34.8) 20 (36.4) 11 (22.9)	19.77	0.001*
Do you think Plastic surgery and Cosmetic surgery are the same?
I Don’t know No Yes	61 (61.6) 119 (70) 73 (61.9)	38 (38.4) 51 (30) 45 (38.1)	2.86	0.239
Is plastic surgery procedure scarless?
I Don’t know No Yes	92 (68.7) 110 (66.3) 51 (58.6)	42 (31.3) 56 (33.7) 36 (41.4)	2.44	0.294
Do you think that plastic surgery is expensive and meant for rich and famous?
Yes No I Don’t know	33 (86.8) 123 (66.8) 97 (58.8)	5 (13.2) 61 (33.2) 68 (41.2)	11.07	0.004*
Do you think plastic and cosmetic surgeries are very risky?
Does not involve any risk. I Don’t know The risk is similar as in other surgeries. They are very risky	8 (44.4) 33 (62.3) 182 (68.9) 30 (57.7)	10 (55.6) 20 (37.7) 82 (31.1) 22 (42.3)	6.54	0.088

* Statistically significant

Furthermore, when comparing age and perception of plastic surgery, students with an aged 26- 30 years had a significant higher percentage of those who reported that plastic surgery is an essential (P-value = 0.028) In addition, those who thought that plastic surgeries are scarless was also higher in those aged 26-30 compared to other age groups (p-value = 0.045) (Table 7).

Table 7. Relationship between students’ age and their perception about plastic surgery
Variable	Age				χ2	p-value
	< 20 N (%)	20-25 N (%)	26-30 N (%)	> 30 N (%)
What do you think about plastic surgery as a specialty?
Essential Like any other specialty Not ethical Not suitable	3 (1.5%) 2 (1.2%) 1 (16.7%) 1 (12.5%)	0 (0.0%) 1 (0.6%) 0 (0.0%) 0 (0.0%)	194 (94.2%) 161 (96.4%) 5 (83.3%) 6 (75%)	9 (4.4%) 3 (1.8%) 0 (0.0%) 1 (12.5%)	18.68	0.028*
Are you interested in plastic surgery?
No Yes	5 (2%) 2 (1.5%)	1 (0.4%) 0 (0.0%)	241 (94.5%) 125 (94.7%)	8 (3.1%) 5 (3.8%)	0.72	0.868
What’s your biggest concern about being a plastic surgeon?
Competitive specialty Ethical and religious issues Getting bored No fears Other	3 (2%) 4 (3.6%) 0 (0.0%) 0 (0.0%) 0 (0.0%)	0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.1%)	139 (92.7%) 104 (93.7%) 21 (91.3%) 55 (100%) 47 (47.9%)	8 (5.3%) 3 (2.7%) 2 (8.7%) 0 (0.0%) 0 (0.0%)	18.96	0.089
Do you think Plastic surgery and Cosmetic surgery are the same?
I Don’t know No Yes	0 (0.0%) 4 (2.4%) 3 (2.5%)	0 (0.0%) 1 (0.6%) 0 (0.0%)	96 (97%) 159 (93.5%) 111 (94.1%)	3 (3%) 6 (3.5%) 4 (3.4%)	3.82	0.7
Is plastic surgery procedure scarless?
I Don’t know No Yes	4 (3) 0 (0.0) 3 (3.4)	0 (0.0) 1 (0.6) 0 (0.0)	128 (95.5) 155 (93.4) 83 (95.4)	2 (1.5) 10 (6) 1 (1.1)	12.86	0.045*
Do you think that plastic surgery is expensive and meant for rich and famous?
Yes No I Don’t know	0 (0.0%) 2 (1.1%) 5 (3%)	0 (0.0%) 1 (0.5%) 0 (0.0%)	37 (97.4%) 173 (94%) 156 (94.5%)	1 (2.6%) 8 (4.3%) 4 (2.4%)	4.74	0.577
Do you think plastic and cosmetic surgeries are very risky?
Does not involve any risk. I Don’t know The risk is similar as in other surgeries. They are very risky	0 (0.0%) 0 (0.0%) 5 (1.9%) 2 (3.8%)	0 (0.0%) 0 (0.0%) 1 (0.4%) 0 (0.0%)	18 (100%) 51 (96.2%) 249 (94.3%) 48 (92.3%)	0 (0.0%) 2 (3.8%) 9 (3.4%) 2 (3.8%)	3.72	0.929

* Statistically significant

Table 8 demonstrated that students in the sixth academic year had a significantly higher percentage of those whose biggest concern was the fact that plastic surgery is a competitive specialty, who thought that plastic surgery is expensive and that it is meant for the rich and famous and who thought that plastic and cosmetic surgeries are very risky with p-values of 0.008, 0.025 and 0.001, respectively. Moreover, upon exploring the relationship between the student’s GPA and their perception of plastic surgery, those with a GPA out of 5 had a significant higher percentage of those whose biggest concern was that plastic surgery is a competitive specialty (p-value = 0.022) (Table 9).

Table 8. Relationship between students’ academic year and their perception about plastic surgery
Variable	Academic year				χ2	p-value
	Third year No. (%)	Fourth year No. (%)	Fifth year No. (%)	Sixth year No. (%)
What do you think about plastic surgery as a specialty?
Essential Like any other specialty Not ethical Not suitable	16 (7.8%) 20 (12%) 1 (16.7%) 2 (25%)	31 (15%) 40 (24%) 1 (16.7%) 1 (12.5%)	46 (22.3%) 28 (16.8%) 3 (50%) 3 (37.5%)	113 (54.9%) 79 (47.3%) 1 (16.7%) 2 (25%)	16.39	0.059
Are you interested in plastic surgery?
No Yes	23 (9%) 16 (12.1%)	46 (18%) 27 (20.5%)	57 (22.4%) 23 (17.4%)	129 (50.6%) 66 (50%)	2.12	0.546
What’s your biggest concern about being a plastic surgeon?
Competitive specialty Ethical and religious issues Getting bored No fears Other	11 (7.3%) 14 (12.6%) 5 (21.7%) 6 (10.9%) 3 (6.3%)	23 (15.3%) 25 (22.5%) 2 (8.7%) 16 (19.1%) 7 (14.6%)	28 (18.7%) 22 (28.8%) 2 (8.7%) 7 (12.7%) 11 (22.9%)	88 (58.7%) 40 (36%) 14 (60.9%) 26 (47.3%) 27 (56.3%)	26.99	0.008*
Do you think Plastic surgery and Cosmetic surgery are the same?
I Don’t know No Yes	15 (15.2%) 18 (10.6%) 6 (5.1%)	24 (24.2%) 30 (17.6%) 19 (16.1%)	20 (20.2%) 37 (21.8%) 23 (19.5%)	40 (40.4%) 95 (50%) 70 (59.3%)	11.64	0.07
Is plastic surgery procedure scarless?
I Don’t know No Yes	12 (9%) 14 (8.4%) 13 (14.9%)	30 (22.4%) 24 (14.5%) 19 (21.8%)	30 (22.4%) 40 (24.1%) 10 (11.5%)	62 (46.3%) 88 (53%) 45 (51.7%)	11.04	0.087
Do you think that plastic surgery is expensive and meant for rich and famous?
Yes No I Don’t know	0 (0.0%) 21 (11.4%) 18 (10.9%)	4 (10.5%) 42 (22.8%) 27 (16.4%)	6 (15.8%) 41 (22.3%) 23 (20%)	28 (73.7%) 80 (43.5%) 87 (52.7%)	14.46	0.025*
Do you think plastic and cosmetic surgeries are very risky?
Does not involve any risk. I Don’t know The risk is similar as in other surgeries. They are very risky	1 (5.6%) 8 (15.1%) 28 (10.6%) 2 (3.8%)	7 (38.9%) 14 (26.4%) 46 (17.4%) 6 (11.5%)	4 (22.2%) 8 (15.1%) 65 (24.6%) 3 (5.8%)	6 (33.3%) 23 (43.4%) 125 (47.3%) 41 (78.8%)	29.75	0.001*

* Statistically significant

Table 9. Relationship between students’ GPA and their perception about plastic surgery
Variable	GPA		χ2	p-value
	Out of 4 No. (%)	Out of 5 No. (%)
What do you think about plastic surgery as a specialty?
Essential Like any other specialty Not ethical Not suitable	81 (39.3%) 68 (40.7%) 2 (33.3%) 4 (50%)	125 (60.7%) 99 (59.3%) 4 (66.7%) 4 (50%)	0.51	0.915
Are you interested in plastic surgery?
No Yes	103 (40.4%) 52 (39.4%)	152 (59.6%) 80 (60.6%)	0.03	0.849
What’s your biggest concern about being a plastic surgeon?
Competitive specialty Ethical and religious issues Getting bored No fears Other	68 (45.3%) 35 (31.5%) 14 (60.9%) 17 (30.9%) 21 (43.8%)	82 (54.7%) 76 (68.5%) 9 (39.1%) 38 (69.1%) 27 (56.3%)	11.43	0.022*
Do you think Plastic surgery and Cosmetic surgery are the same?
I Don’t know No Yes	45 (45.5%) 68 (40%) 42 (35.6%)	54 (54.5%) 102 (60%) 76 (64.4%)	2.18	0.336
Is plastic surgery procedure scarless?
I Don’t know No Yes	56 (41.8%) 62 (37.3%) 37 (42.5%)	78 (58.2%) 104 (62.7%) 50 (57.5%)	0.89	0.639
Do you think that plastic surgery is expensive and meant for rich and famous?
Yes No I Don’t know	17 (44.7%) 66 (35.9%) 72 (43.6%)	21 (55.3%) 118 (64.1%) 93 (56.4%)	2.57	0.277
Do you think plastic and cosmetic surgeries are very risky?
Does not involve any risk I Don’t know The risk is similar as in other surgeries. They are very risky	11 (61.1%) 22 (41.4%) 98 (37.1%) 24 (46.2%)	7 (38.9%) 31 (58.5%) 166 (62.9%) 28 (53.8%)	5.12	0.163

* Statistically significant, GPA: grade point average

Students at Jeddah University had a significantly higher percent of those who were interested in plastic surgery compared to students from other universities (p-value < 0.001) (Figure 1). Students at King Saud Bin Abdulaziz University had a significantly higher percentage of those whose biggest concern about being a plastic surgeon is that it is a competitive specialty (p-value < 0.001) (Figure 2).

Figure 1. Relationship between students’ college and if they are interested in plastic surgery

Figure 2. Relationship between students’ college and their biggest concern about being a plastic surgeon

Students at Ibn Sina National College had a significantly higher percentage compared to those who thought that plastic surgery and cosmetic surgery are the same and who thought that they are very risky (p-value < 0.001) (Figure 3, 4).

Figure 3. Relationship between students’ college and if they think plastic surgery and cosmetic surgery are the same

Figure 4. Relationship between students’ college and if they think plastic and cosmetic surgeries are very risky

Discussion

In Saudi Arabia, there are limited training options for plastic or reconstructive surgery (16), and it would be advantageous to learn the medical students' attributes, characteristics, and other factors that influence their decision in pursuing this surgical subspecialty. Thus, our study explored the knowledge and perceptions of plastic surgery among medical students pursuing their degree in the Western region of KSA. The study findings showed that the majority of the students reported that they have little knowledge regarding this specialty. A recent study done among undergraduate male medical students in one of the universities in Saudi Arabia showed that 68% of them reported good knowledge regarding plastic surgery (14). Approximately 89% of the students agreed that they took rotation in plastic surgery during their internship. In Saudi Arabia, to get a residency seat for plastic surgery, applicants should have above-average academic achievement and a high number of scientific publications (17). The female students showed significantly higher knowledge about this subspecialty than male students in this study. This finding is also reported in other studies done by Mortada et al. in Jeddah, Saudi Arabia (18). The possible explanation for this could be that females are more concerned about body appearance and cosmetics than males (19). This would have made female students inquire and acquire more information about plastic surgery and think of it as a career option. It may be more difficult to develop a competitive application if students do not have good knowledge about the specialty. Efforts should be made to allow students to attend more clinical rotation in the plastic surgery department and clinics early in their training period, a time where students have more time on their hand for a better understanding of plastic surgery and its career opportunities.

In this study, only 34.1% of students were interested in taking plastic surgery, and this lesser interest can be related to poor knowledge about this specialty and its opportunities or due to the high competitiveness of the specialty. It was also found that students belonging to a few schools showed greater interest in taking plastic surgery as a career option after graduation. This could be explained on the basis of differences between schools in exposure to plastic surgery during undergraduate medical training (20). There is a need to restructure the formal teaching methods in plastic surgery, and this should include a brief but broad overview of this specialty during the first two years of undergraduate medical training. The curriculum could include didactic lectures, workshops for skill developments, computer-assisted learning, mandatory rotations in plastic surgery clinics during clinical years, or a combination of the above strategies (21). Regardless of which teaching modality is used, students should be formally assessed on what they learned as this would motivate them to transform their understanding to its application. Also, students should be encouraged to participate in case-based learning related to plastic and reconstructive surgery, which can be another effective way to improve the understanding of the specialty. One of the issues faced in this regard is that surgical specialties are facing difficulties in converting the considerations of students into genuine interest. It is reported that students who were interested in surgery during their undergraduate training were more stable in retaining their choice for residency in surgery (22). Therefore, efforts should be made by focusing on student groups who are career-malleable and inquisitive about plastic surgery, as this could lead to a higher probability of continuing on to a plastic surgery career. This is supported by other studies, which report that early exposure to surgical specialties could positively influence career choice (23, 24). Evidence also shows that resident mentoring and role modeling could increase the students' perceptions and career choices (25, 26). The study findings highlight that there is a misconception about plastic surgery among medical students as the mainstream media displays it as synonymous with cosmetic or aesthetic surgery, which could influence the attitudes of students who have not attended clinical rotations or had enough exposure to this specialty. The inclusion of plastic surgery in the undergraduate medical curriculum is also a controversial and debatable topic, and evidence shows that this specialty is underrepresented in the curriculum in most medical schools (27). This study signifies the need for the incorporation of plastic surgery into the curriculum as this does not increase the knowledge regarding the specialty but also improves the students' clinical decision-making skills.

One of the major limitations of the study is its cross-sectional approach as these involved only medical students from the western region of Saudi Arabia. Therefore, the knowledge level and perceptions are not representative of all medical students in the country. Secondly, we didn't assess the actual exposure and training that student received in their respective institutions. And finally, our findings were based on self-reported responses, which could have resulted in social desirability bias.

Conclusion

The study findings showed that the knowledge and perception about plastic surgery are not that satisfactory among medical students. The poor understanding of the specialty's significance and its future opportunities could have made most medical students not to consider it as a carrier option. Students should be more exposed to clinical rotation in plastic surgery departments for better outcomes. Resident mentoring and role modeling could also improve the students' perceptions and career choices.

Disclosure

Statement:

The authors declare no conflict of interest.

Funding:

None.

Ethical Consideration:

The study was approved by the ethical committee of directorate of health affairs in the western region with approval number A01171 and registration number H-02-J-002.

Data Availability:

The survey used in the study is found within the supplementary materials.

Author Contribution:

All authors equally contributed to conceptualizing, drafting, searching the literature, writing, language editing and proofreading the manuscript.