Keywords
plastic surgery - cosmetics - medical students
Introduction
Plastic surgery is concerned with the treatment of deformities of the skin and subcutaneous
tissues in an attempt to improve functionality and appearance.[1] It is often thought to consist only of its cosmetic aspect, dealing only with improvement
of appearance.[2] It, however, comprises multiple subspecialties such as breast surgeries, cleft lip
surgery, hand surgery, maxillofacial trauma, burns, mammoplasty, abdominoplasty, liposuction
among others.[2] In spite of this diversity, several studies across different continents have shown
that it is still poorly understood by many, including primary care physicians and
medical students.[2]
[3]
[4]
[5]
[6]
[7] From these studies, a dearth in knowledge surrounding plastic surgery and particularly
a mixed attitude toward its practice has been reported.
Pertaining to the knowledge surrounding plastic surgery, many of the students failed
in differentiating cosmetic surgery from plastic surgery. There was also a paucity
of information on the subspecialties of plastic surgery as well as procedures and
conditions treated by plastic surgeons. Further, in a study done in Nigeria, most
of the students were not aware of the institutions practicing plastic surgery in their
locale.[7]
With regard to their attitude, a study done on medical students in Saudi Arabia revealed
that most of them did not consider plastic surgery as a prospective field they would
venture in.[8] They, however, reported that they would avail themselves for the procedure if need
be. It is plausible that most of the students in the studies had prior knowledge but
poor attitude toward plastic surgery. This may be due to their source of information
and inadequate professional/medical exposure to plastic surgery.
Studies have shown that most students derive their information on plastic surgery
from friends, television shows, and the internet. Very few derive their information
from hospitals or doctors themselves.[7]
[9] Conyard et al revealed that exposure of medical students to plastic surgery by medical
professionals increased their scope of the practice and vice versa. As a result, poor
knowledge and attitude could be attributed to either inadequate professional exposure
or inaccurate information from media sources.[7]
Awareness of plastic and reconstructive surgery by medical students has multiple implications.
First, the lack of awareness has repercussions for both future surgical and nonsurgical
trainees who usually form a significant referral base for practicing plastic surgeons
and plastic surgery as a field. This may result in a biased exposure of medical students
to inaccurate information than from the professionals.9 Second, an improved understanding
of plastic surgery would expedite the referral process for patients in need of the
services of plastic surgery, reducing the psychological and financial costs to both
patients and the health care system.[8]
[9]
[10] Increasing the exposure to accurate information from the professionals could therefore
have significant impact for both the future of the field and the local residents.
Due to scanty data and elusive medical reports, it is not known if the same issue
is reflected in Kenyan setting. This study therefore sought to find out the knowledge
and attitude of Kenyan medical students toward plastic surgery.
Materials and Methods
The study was a cross-sectional study that randomly recruited 108 medical students
in their 2nd to 4th year of study at the University of Nairobi, Kenya. The sample
size was arrived using the formula suggested by Charan and Biswas[11]:
where n is sample size, z is the standard normal variate (taken as 1.96 at 95% confidence interval) and P is the expected proportion of interest in a population. The variable used was “where
the students got this information from” and we aimed to see how many got it from the
appropriate sources. Almeland et al,[12] showed that 8% of medics got their information from textbooks, thus the value of
P (proportion) was taken as 0.08 and d is the effect size (taken as 0.05). With these values, a sample size (n) of 108 was arrived after calculation.
The 2nd and 3rd years were chosen since they had not yet been introduced to plastic
surgery which is done in the 4th year of medical school, at the University of Nairobi.
The difference between the years would, therefore, serve as a good opportunity to
assess whether professional/medical exposure to plastic surgery influences attitude
toward the field. The senior years, 5th and 6th-year medical students were not included
in the study since at the time of the study, they were taking their final examinations.
Prior to the administration of the questionnaires, ethical consideration was sought
from the Kenyatta National Hospital and University of Nairobi Ethics and Standards
Committee as well as the Dean, School of Medicine, University of Nairobi.
Prior to any data collection, both verbal and written consent was sought from the
participants following which they filled the structured questionnaire. The questionnaire
was structured from previously mentioned studies to maintain consistency and hence
validity ([Supplementary Material], available in the online version). The initial part of the questionnaire asked about
the age, sex, race, and year of study of the respondent. In assessing their knowledge,
the following questions were asked: “define cosmetic surgery,” “list conditions treated
by plastic surgeons,” “list operations/procedures performed by plastic surgeons,”
“from where did you learn about plastic surgery,” “list any risks associated with
plastic surgery,” “are you aware of plastic surgery is being conducted in your locale.”
In assessing their attitude, the following questions were asked: “would you like to
be a plastic surgeon,” “would you consider having a plastic surgery,” “would you be
embarrassed if your immediate family,” “would you be embarrassed if your close friends
knew you underwent plastic surgery.”
Data collected were coded into SPSS (version 21. IBM) and presented in percentages,
means, and standard deviations. Mann-Whitney test was done to assess for gender differences
and Kruskal–Wallis test for assessing the statistically significant difference between
the year of study and the questions. For the different questions asked, the respective
findings were presented in tables.
Results
Out of 108 respondents, 48 were male and 60 were female. One hundred (93%) of them
were between 18 and 24 years and eight (7%) were above 24 years. Twenty-eight (26%)
of the respondents were in their fourth year of study, 52 (48%) were in their third,
and 28 (26%) were in their second year ([Table 1]). Majority (96%) were Africans (Kenyans), while 4% were from the Asian community.
Table 1
Table showing the distribution of responses per year of study (N = 108)
|
Year of study
|
Number of participants
|
|
4th year of study
|
28
|
|
3rd year of study
|
52
|
|
2nd year of study
|
28
|
Knowledge
When assessed on their definition of plastic surgery, most of the respondents (95
out of 108) 88% described it as surgery that is done to improve appearance. Three
out of 108 (3%) defined it as corrective surgery, (2 out of 108) 2% as reconstructive
surgery, (1 out of 108) 1% as repair of tissues, (1 out of 108) 1% as beautification,
(1 out of 108) 2% as reconstructive surgery, and (1 out of 108) 1% as the placing
of implants. There were no significant differences on the responses given based on
the gender or year of study ([Table 2])
Table 2
Table showing the results of Mann Whitney and Kruskal–Wallis tests (N = 108)
|
Question
|
Mann Whitney test (p-value): assessing gender differences
|
Kruskal–Wallis test (p-value): assessing difference based on year of study
|
|
Define plastic surgery
|
0.445
|
0.325
|
|
What are the conditions assessed by plastic surgeons?
|
0.114
|
0.425
|
|
What are the risks associated with plastic surgery?
|
0.231
|
0.665
|
|
Are you aware of plastic surgery centers in Kenya?
|
0.009
|
0.995
|
|
Would you want to be a plastic surgeon?
|
0.128
|
0.157
|
|
Do you know any risks associated with plastic surgery?
|
0.439
|
1.743
|
|
Would you consider having a plastic surgery?
|
0.238
|
1.623
|
|
Would you be embarrassed about undergoing a plastic surgery if your immediate family
knew?
|
0.242
|
0.420
|
|
Would you be embarrassed about undergoing a plastic surgery if your close friends
knew?
|
0.154
|
0.315
|
The respondents were also assessed on the conditions that are handled by plastic surgeons.
Trauma was identified as the main condition (68 respondents) followed by cleft lip
(25 respondents), cleft palate (16 respondents), and finally scars (nine respondents).
Liposuction was the most common procedure (49 respondents), followed by breast enhancement
(46 respondents) and rhinoplasty (24 respondents). Overall, most students suggested
four to six procedures irrespective of the year of study. There were no significant
differences on the responses given based on the gender or year of study ([Table 2]).
Sixty-four percent of the respondents noted that there were risks identified with
plastic surgery whereas 34% did not. The remaining 2% were not sure as to whether
there were any risks involved. The most common risk noted was infections (39 respondents),
death (17 respondents), and rejection (11 respondents). There were no significant
differences on the responses given based on the gender or year of study ([Table 2]).
On the availability of the procedures in Kenya, 86 out of 108 respondents (79.6%)
noted that it was available whereas 22 (20.4%) noted that it was not available. There
was, however, a significant difference based on gender on the awareness (p-value = 0.009) with female students being more aware than the males following Mann-Whitney
test but no differences noted based on the year of study ([Table 2]).
With regard to initial exposure to plastic surgery-related content, 55% noted that
they heard it from the television, 19% from the internet, 12% from school, 11% from
social media, and 3% from friends.
Attitude
The respondents were then asked if they would want to pursue plastic surgery in their
future practice. Sixty-two percent of the respondents reported that they did not,
37% agreed that they would whereas 1% were not sure. When assessed if they would consider
a plastic surgery being done on them at the moment of answering the questionnaire,
majority (75%) denied. The majority of the respondents (52%) also refused to undergo
surgery in the near future. There were no statistically significant differences based
on the gender or the year of study ([Table 2]).
When assessed on the factors that would influence their choice of undergoing surgery,
such as the influence of family and friends, 77% of the respondents reported feeling
embarrassed to undergo the surgery if their family knew. Seventy-seven percent (77%)
also reported feeling embarrassed if their friends knew. There was no statistically
significant difference based on the gender or the year of study ([Table 2]).
Discussion
Data from our study tend to suggest that medical students have some awareness of plastic
surgery but a poor attitude to the same. Similar studies done in different populations
especially those in the developing world tend to support this.[2]
[8]
[9]
[13]
Knowledge
From our findings, the majority of the students identified plastic surgery with cosmetics
with many describing it as a surgery meant to improve appearance. Similar findings
were noted among the health care professionals in India (80%) who thought it principally
served cosmetic purposes.[13] When further asked about the conditions handled in plastic surgery, many of the
students cited trauma, cleft lip, cleft palate, and scars as the main conditions.
Our findings were different from that of a study done in Saudi Arabia where the most
common conditions noted were burns, lifting and tightening of the face, breast reconstructions
and wound management.[9] In the Indian populace, burns were mostly noted to be handled by plastic surgeons
(20.4%) as well as ulcers and cleft lip/palate. Even though most students could easily
mention some of the conditions and procedures handled by plastic surgeons, their knowledge
on the same was limited.[13] This may be due to poor exposures of plastic surgery in the respective populations.
Findings from our study also showed that the common procedures thought to be done
by plastic surgeons included liposuction (41%), breast enhancement (37%), and rhinoplasty
(21%). In a comparative Nigerian study, the conditions handled by plastic surgeons
were noted to be: removal of tattoos, breast augmentation/reconstructions, facelift,
Botox and rhinoplasty.[7] Further, in India, the conditions that were majorly noted to be handled by plastic
surgeons were hypospadias, liposuction, breast augmentation or reduction, hair grafting,
and rhinoplasty. In Saudi Arabia, rhinoplasty, breast enhancements, and blepharoplasty
were noted.[9] In Canada, students reported that plastic surgeons mostly perform hair transplant
surgery (89.9%), facial scar surgery (88.0%), and rhinoplasty (83.4%).[10] In the Nigerian population,[14] the most common procedures were liposuction (88.2%) and hair transplant surgery
(84.4%); in contrast, liposuction was named by only 53% of our study participants.
The differences noted in the procedures being performed by plastic surgeons may be
due to the different levels of professional/medical exposures on plastic surgery to
the different populations.
Majority of the students agreed that in deed there were risks associated with plastic
surgery, with the major ones being infection and death. Similarly, a study done in
India was in support that plastic surgery bore risks.[13] Their analysis, however, was not specified.
Majority of the respondents reported demonstrated awareness of the availability of
plastic surgery procedures in our setting. Our findings are different from that of
Isiguzo et al[7] who reported a minority demonstrating such awareness among the Nigerian population.
Furthermore, female participants were noted to be aware of plastic surgery services
than males. This may be because, in our setting, most of the exposure may be from
inaccurate sources leading to a biased tendency for females to seek corrective surgery
compared with males.
Attitude
Data from our findings showed that most students would not want to pursue plastic
surgery in the future. Our findings were similar to separate studies done in Saudi
Arabia where in one sample 38.8% of the students wanted to pursue plastic surgery,
while in another, only 11%.[8]
[9] There was no gender or year related difference noted.
Also, majority of the students in our setting displayed unwillingness to undergo plastic
surgery. Our findings were different from those by Isiguzo et al[7] where most of the students in the Nigerian population were willing to undergo plastic
surgery if presented with the option. The difference may be due to the influence of
culture as well as the family and friends. In our setting, 77% of the respondents
reported feeling embarrassed to undergo the surgery if their family knew and 77% also
reported feeling embarrassed if their friends knew. The role of family and friends
as noted then may explain the difference in the willingness to undergo plastic surgery
as seen between our setting and that of Nigeria.[7]
It is worth noting that in our setting, most students reported hearing of plastic
surgery from the television (55%) and the internet (19%). This was similar to Isiguzo’s
study where the internet (15.7%), friends (15.7%), and television (14.8%) were noted
to be the main source of their information.[7] Easy access to television and internet devices in our age and era may explain the
reason why most of the students get their information from these sources. Most satellite
TV packages, films, and media available today have stations devoted to aesthetic plastic
surgery[15]
[16]
[17]
[18] and as a result, may act as a source of information for the students. The difference
noted in the sources of information might arise due to the availability of the television
and internet in the area of students’ study. Studies done have shown that professional/medical
exposure to plastic surgery improves students’ knowledge of the scope of practice
and may influence their knowledge and attitude of the same.[7]
[9] Therefore, more efforts should be made toward promoting this professional/medical
exposure. Further, information passed through the internet and television should be
verified to ensure that the right information is being passed.
Limitations
In this study, we assessed students strictly from the University of Nairobi who might
have different exposures as compared with those from other settings. Similarly, the
university is located in an urban setting, and this might have biased the results
(on matters such as awareness of plastic surgery facilities). We therefore plan to
conduct similar studies in other universities in both urban and rural setting and
hopefully compare the results to assess the effects brought about by being in different
universities.
Conclusion
The students in our setting had some awareness about plastic surgery but had a poor
attitude toward it. Increased professional outreaches and professional/medical exposure
are therefore advised.
