Transgender Surgery with Keelee MacPhee, MD
In Episode 22, Erin Everett, NP-C, welcomes Dr. Keelee MacPhee, a transgender plastic surgeon in the Raleigh-Durham, North Carolina area, who specializes in various transgender surgical procedures. During the episode, the two discuss transgender surgeries including rhinoplasty and facial feminization, gender nullification, vaginoplasty, FtM top surgery, and insurance coverage/informed consent for transgender surgeries.
About This Episode
Episode 22 Transcript
Transgender Surgery with Dr. Keelee MacPhee
Introducing Dr. Keelee MacPhee
Erin Everett: Hey everybody. Welcome back to Exclusively Inclusive. I’m your host, Erin Everett, a nurse practitioner. On today’s episode. I’m really excited to introduce Dr. Keelee MacPhee. Dr. Keelee MacPhee is a gender surgeon and cosmetic plastic surgeon who’s been practicing for over 15 years. She’s located in the Durham, North Carolina area, but obviously receives patients from all kinds of surrounding areas. She’s really passionate about transgender medicine and making sure that her patients become more comfortable in their own skin and more confident in providing affirming care. She focuses on breast surgery, genital reconstruction, cosmetic enhancements, and general cosmetic surgery as well. She’s been practicing since 2005 and primarily does surgery at the Duke Regional Hospital, which is part of Duke University Health System.
Erin Everett: Dr. MacPhee earned her undergraduate degree at University of Massachusetts in Amherst finishing with summa cum laude, which is no surprise. She’s brilliant, she’s smart, she’s passionate, and she provides a warm, caring environment for all patients to receive care, particularly those ones in the gender community. Without further ado, I’d love to introduce Dr. Keelee MacPhee. Well, welcome to the show Dr. Keelee MacPhee.
Keelee MacPhee: Thank you very much.
Erin Everett: Tell us a little bit about yourself, maybe a fun fact and your chosen pronouns, that type of thing.
Keelee MacPhee: Okay. Sure. Well, my name, first of all is, I was named for Jean-Claude Killy and he was in the Olympics in 1968, the downhill skiing, and so I was named for that gentleman. Yeah, but just spelled differently. My pronouns are she and her, and so I’m cisgender. I work primarily with the umbrella term of transgender patients.
Erin Everett: Excellent. What brought you into this field of working with the transgender community?
Keelee MacPhee: Well, it was a surprise, kind of landed in my lap. In 2005, I started my own practice in Raleigh. At that point I went around the community of plastic surgeons to introduce myself. One older gentleman was somewhat secretly, working on transgender patients and his wife wanted him to get out of that. It happens, right at that time when I walked into his office to say hello, and he suggested that I get involved and start working with these patients if I was interested. Of course I said, “Sure,” so it grew from there. Initially I was doing all of plastic surgery, so general plastics and a lot of breast cancer reconstruction. You name it, I was doing it. But as time went by, my favorite patients were always the transgender patients that I got to work with.
Keelee MacPhee: That grew with word of mouth and then marketing and I eventually felt like I was burned out with the breast cancer and that sort of challenging side of patients that were still passing away. I was always so happy to get to work with my trans patients that I decided, “I’m going to focus on this.” That was in 2014 that we decided to just focus everything on the trans patients. I, at that time, also went for some training. In 2014, there were no training programs for doing a vaginoplasty surgery. I was going to different trans conferences and meeting other surgeons and asked if I could watch them do their surgery and learn from them, and I was encouraged by a couple of them. That’s how I started off with learning how to do the vaginoplasty.
Erin Everett: Wow, that’s so cool.
Keelee MacPhee: Yeah.
Erin Everett: Yeah. I mean, to your point, it’s such a rewarding community to work with because most of the stories are happy. To see a patient and provide them the affirming care and just see them so much happier in their own skin is just an amazing experience really.
Keelee MacPhee: Absolutely. I’m so lucky to be a part of that. The transformations that I see are incredible. I’m glad that you get to take part in that too, because it’s very rewarding. Having somebody come in who won’t look you in the eye and they’re so anxious and depressed, transforming into a bubbly, happy, confident person is amazing. That’s just the best part of the day, to get to see somebody transform in that way.
Erin Everett: I totally agree. You offer a wide variety of procedures at your clinic that you do for, not just regular plastics, but also affirming surgeries. Out of all of those, what would you say is your most fun? What do you prefer to do?
Keelee MacPhee: Oh, wow. Let’s see. The most intriguing and fun is a rhinoplasty.
Erin Everett: Oh really?
Keelee MacPhee: Yeah. We don’t do a lot of airway work, meaning helping improve breathing, but it often does go hand in hand with the aesthetic changes. That’s great to help somebody breathe better on a daily basis. But the detailed work of the rhinoplasty, getting to work with their cartilage and reshaping that, is a whole lot of fun in the operating room. It’s great because I can see how things are going to look and then we have to be really patient because it takes about a year for all the swelling to go down after that surgery. But that’s a great-
Erin Everett: Oh, wow!
Keelee MacPhee: Yeah, it’s a long time. It’s a very slow recovery process, but it’s a lot of fun to get to do that one.
Erin Everett: That’s so interesting. I never knew that it took that long to get your final product. That’s a lot of patience.
Keelee MacPhee: Yeah, it is. It does. You can imagine we’re reshaping all the underlying structure, and so the overlying skin needs shrink down and conform, so that’s a slow process, but it’s worthwhile for sure-
Erin Everett: That’s awesome. With that, does that play into your facial feminization? Do you find yourself doing that more with the trans community or do you do that more with the cis community?
Keelee MacPhee: Well, I actually have primarily trans community as my patients now.
Erin Everett: Oh, that’s so cool.
Keelee MacPhee: Because we are doing that in conjunction with facial feminization a lot of times, and we’ve just focused so much on our trans clientele that oftentimes people, they’ve had some other gender-affirming surgery and they’ll come in for a rhinoplasty too, which may or may not be related to their gender identity, but usually it seems like more and more where the person or the clientele is going to be contacting me just because of our connection with the transgender surgeries.
Erin Everett: Mm-hmm (affirmative). Yeah. Well, that makes sense. I knew you had a focus on trans care, but I didn’t realize that that’s the bulk of your patients. I think that’s really cool.
Keelee MacPhee: Yeah, it is. We do still work with anybody of any gender identity, but more and more, I would think now we’re at like 90, 95% of our clientele are coming in for some gender-related surgery.
Erin Everett: Okay. With that in mind, what kind of experience would they expect in your office, with your front staff? I mean, I assume that they’re all culturally sensitive to the needs.
Keelee MacPhee: Oh, completely. Well nowadays because of COVID, everything’s going on through the internet, email, and phones. But I have a really small office and Sue is the person that people would be talking to before they get to talk with me. She is always getting compliments from our clients because she’s so patient and kind, and she’s been working with me for years and years. She’s fully conscious and trained with working with anybody of different identities.
Erin Everett: Oh, that’s great. Most of your patients will interact with her at some point.
Keelee MacPhee: Yes. Oh, definitely. Sure. She’s vital for getting anybody into the operating room. I’ll be doing medically-related or surgically-related information while she’s doing all the administrative work for helping everybody.
Erin Everett: Okay. That’s wonderful.
Keelee MacPhee: Yeah. Mm-hmm (affirmative).
Transgender Surgery Insurance Coverage Considerations
Erin Everett: Do you find that most of your procedures, are commercial payers starting to pay for more of them or are people still paying out-of-pocket?
Keelee MacPhee: I would guess at this point about 75% of our people are getting some insurance coverage, which is amazing. Because in 2014, when we started focusing primarily on gender, nobody was covering it, and it was really, really frustrating. Actually at that point I got out of insurance networks because they were so unreliable or really defeating to work with in many ways. Over the years, we’ve always helped everybody that has the insurance benefits to get pre-authorized for surgery and then to get reimbursed as much as possible because we require the surgeon’s fee upfront, just like with most dental practices. We’ll ask for the surgeon’s fee and then help people get reimbursed on the backend, and that’s worked out well. As long as we get pre-authorization for everybody, we have succeeded in getting reimbursement nicely. It’s great that more and more insurance companies are covering the procedures. I think a lot of that has to do with large organizations, corporations that people have their insurance through have supported providing the care for trans surgeries, so that’s helped a lot.
Erin Everett: Yeah, I think you’re right. I mean, I have talked to patients before who had felt very defeated when, say top surgery is covered but their facial feminization surgery is not covered and have encouraged those patients to then go to and talk to their HR. Because I try to explain to them, if you’re not in the field, you don’t necessarily know that that’s an affirming surgery that’s medically required. Then they’re able to being able to get it written into their insurance policy.
Keelee MacPhee: Yes, which is awesome. For these large corporations, it really is not costing them very much money. I do the same thing for sure.
Erin Everett: Yeah. This is ignorance.
Keelee MacPhee: Mm-hmm (affirmative). Yeah. Recently we had somebody whose genital reconstruction was covered, but then her breast augmentation was not, and they had actually eliminated it completely. Even though I talked to their medical director they said, “No, not going to happen,” which is really frustrating.
Erin Everett: Yeah, and you’re like, “Why?” It doesn’t make any sense just cherry-picking what they’re going to cover.
Keelee MacPhee: Mm-hmm (affirmative). Yeah. Hopefully more and more will start to realize. The other thing that’s really rare to get covered is facial feminization procedures. That is always a surprise when the insurance said, “Yes, we will help with that.”
Erin Everett: Yeah. No, I would agree. Most people end up paying out-of-pocket for that no matter where they go, but it was unique for this one person to be able to get it covered and added into their benefits. Huge advocacy work there.
Keelee MacPhee: Yeah. Yeah, that’s great. What is it like in Georgia for state coverage? In North Carolina we had full coverage and then had a state treasurer eliminate all of the transgender coverage from the state health plan. They’re being sued, fortunately, by a bunch of our patients and Lambda Legal. They’re pursuing this in North Carolina, but what has happened in Georgia?
Erin Everett: As far as I understand, and do not quote me on this because I feel like it varies a lot. But I recently learned that, with the state plans, that they originally used to cover top surgeries and everything, and now it’s not all inclusive. There’s a lot of exclusions to it, they’re making it very challenging. I do think, I was talking to somebody about this recently actually, that they are trying to take legal action because some of those rights were being taken away for the coverage.
Keelee MacPhee: Yeah. Well, hopefully all 50 states will finally have that available for everybody. But it’s piecemeal at this point in time.
Erin Everett: Right. Right. Exactly. In general, one of our biggest payers for Georgia State Insurance does a pretty good job if you use the right codes and whatnot. Sometimes you have to get a little creative, but they do cover it, but just not everything that they used to. But that’s an ever-moving target too. Actually, I mean, because I work more trying to get medications and such covered, and I’ve seen a huge expansion on that in general as far as getting hormones. Because it used to be like, we only did injectable testosterone because people could get it affordably on GoodRx because no one was going to pay for it.
Erin Everett: Now I can get that covered and even some newer branded oral testosterones that are very new are getting covered for people in the gender community. Not big payers like United, but other ones, Blue Cross Blue Shield, Ambetter, those ones are definitely covering those types of therapies. It’s just amazing because, back when I first started doing transgender medicine, it wasn’t. You really had to just do slim pickings on what you could get, and then you also try to link people up with different programs that were going to give them ‘scholarship money’ to help pay for their medical expenses.
Keelee MacPhee: Right. Right.
Erin Everett: Yeah, so in that regard I have seen a huge expansion in coverage. But in general, no, it’s still very limited.
Keelee MacPhee: Got it.
Erin Everett: Does that ever change your requirements for surgery when someone’s preparing to come to you for say vaginoplasty or top surgery?
Keelee MacPhee: Well, if they’re using insurance, then we have to jump through the hoops that the insurance company wants. Is that what you’re asking?
Erin Everett: Yeah. Mm-hmm (affirmative).
Keelee MacPhee: Yeah. When we don’t use the insurance I use informed consent. But the insurance companies all have their own set of rules. Primarily, they’re following the WPATH standards of care that were a couple of years old actually. But when we have insurance benefits, we have them usually get two letters of mental health providers support showing that they’ve been living full-time as female for a year. Oftentimes they ask that the patient’s been on hormones for a year. Those are the standards that most of the insurance companies ask for.
Erin Everett: Okay. But for you yourself, if you’re not billing insurance you don’t require those types of letters. Is that correct?
Keelee MacPhee: That is correct.
Erin Everett: Okay. Well, that’s nice to know because that can be a roadblock for patients.
Keelee MacPhee: It can be, and it’s really annoying. The insurance company is going to do what they’re going to do. I don’t want to be blocking people. For example, I’ve had patients that have lived full-time for 20 years, decades of their life have lived full-time in their new identity. I’m not going to make them go back to get counseling done so that then they can produce a letter. That would just be ridiculous in my opinion. That’s just one example. Yeah.
Erin Everett: Yeah, I completely agree. I think informed consent should be enough for everybody. I always connect people with mental healthcare providers for transitional support and just because who couldn’t use therapy sometimes? But I don’t think that it should be a requirement to get any sort of affirming care.
Keelee MacPhee: Oh, I agree. Thankfully, more and more people are leaning in that direction is what I’ve seen. Like Planned Parenthood up here were the few of the available providers to go to for hormones, and for a long time they required the letters before they would start providing hormones. But they’ve changed that, and I think that’s awesome that they’ll use informed consent now.
Erin Everett: Yeah. I think we’ll see more change if WPATH decides to update their guidelines, because I feel like it is outdated and a lot of people lean back on that because they’re not sure. I think, in general, some people who are less versed in it or are just getting their feet wet with the trans community are a little bit more nervous because it’s a litigious country and I just don’t see that with that type of community. I mean, people don’t ever turn around and say, “I wish you wouldn’t have done this.” You’re never going to be able to pull those letters out and be like, “Well, I had this letter here to prove.” It’s just crazy. It’s nice though that you don’t require that even for cash pay patients because some people do even for simple orchiectomies.
Keelee MacPhee: Yeah. I understand they do. Yeah. I actually do a bunch of education for physicians in my presentations. I’ll mention what the WPATH standards are, but also try to explain why I don’t require those letters or that same stipulation, because it’s unfair for a patient. It’s great that more physicians are learning about this.
Erin Everett: Yeah. Yeah. They’re more open to providing this safe, affirming care, but definitely still, I mean, I appreciate that you do all that education because I definitely think that it’s very much needed. I don’t know of anybody in Atlanta doing anything even close to a vaginoplasty or type of feminizing surgeries.
Keelee MacPhee: Yeah. Which is too bad because it would be nice if… I mean, it’s the Mecca for the South, having people right there so that patients didn’t have to travel so far would be nice.
Erin Everett: Yeah. I mean, we have huge healthcare systems that would have the ability to incorporate that, and I just don’t understand, so maybe one day.
Keelee MacPhee: Yeah. Well, I guess my inclination for that is that we’re in the conservative South. Fortunately that’s changing in many ways and people are learning, when their child is talking to them about their identity, they become a lot more interested themselves in figuring out what’s going on. With more personal stories and publications about it, I think it’s helped parents hugely in the area. It’s going to change, it’s going to continue to grow.
Erin Everett: Yeah, I agree. I agree. I’ve already seen it change so much just in the last five years.
Keelee MacPhee: Yeah. Well, seriously, when I started working on patients in 2005, everybody was stealth. Meaning, they correctly felt like their lives were in danger if they were out. Everybody’s that I operated on for their top surgery or whatnot at that point, they had already lost their family, they oftentimes had lost their jobs, and so they were secretly living this way. That has completely changed now, for the better. Everybody’s got family coming with them to the office or partners, husbands and wives that are supporting them, which is awesome. It’s so much better for the individual to have their supportive family, friends, community, whoever it might be, helping them through this.
Erin Everett: Since you have been through that evolution with those patients, what would you say to the person who is still considering transitioning but is concerned about what their family might say. Now that you’ve seen the start and the end, and the finish, would you say to them that it’s worth it? Obviously you can’t give solid advice on that, 100%, but would you have any words of wisdom for them?
Keelee MacPhee: Oh, well communication is my go-to for that. It’s multi-pronged I guess. I would want that person, that individual, to be working with therapy, somebody who’s actually well-trained and working with gender identity patients. What they’re going to benefit from directly, if they could bring a parent or whoever is in their family in to talk with them to any of the counseling visits, that can be really beneficial too. It takes a ton of courage. I guess in the end, after having seen people who were much more mature in their 60s and 70s coming in and saying, “I wish I had done this when I was a kid.”
Keelee MacPhee: I can tell these patients confidently that, “If you have explored this internally and you’ve worked with your counselor, I think that you’re going to be very much more happy with your life if you go ahead and pursue this earlier rather than later.” It’s never an easy road. I don’t think that’s going to change instantly, it’s still going to be hard. But I think it’s harder for people who have lived in denial for decades rather than the people who have figured out, “Oh man, I can do this successfully now and be happy, be comfortable.” Of course I’m biased, but I’m in full support of, if you’ve explored this and you’re comfortable with this sort of situation for yourself, do it.
Erin Everett: I think that’s awesome. Yeah. Ever since I started the podcast as well, and just doing more marketing, I find a lot more people over the age of 40 to 50, even in their 60s like you mentioned, wanting to start their transition. Particularly I see the older clients being in more trans-feminine. They were more inclined to put their transition on hold, but have a lot of regret about doing that. When I see them and they’re on their medications and they start seeing physical changes and then just the light return to their eyes and their happiness. Then when they get connected with people like you who can do the rest of their transition and their gender affirmation to whatever comfort level they’re pursuing, it’s just so rewarding.
Keelee MacPhee: Right. Yeah.
Erin Everett: It’s probably one of the best.
Keelee MacPhee: Yeah it is. Sadly, several patients of mine recently had their spouses pass away, but that actually was then their opportunity to finally transition fully. They were putting everything on hold for other people instead of focusing on themselves and their own true happiness. I can understand, like I said, it’s going to be hard for sure. But so then, 70 years old finally get to live the way you want to live is incredible. Sad that they put it off for so long, but yet finally they get to do it and that’s really awesome.
Erin Everett: Yeah. Totally liberating. You’re right. I just wish that more people would take that leap of faith because sometimes people do have a lot of losses, whether it’s family loss and whatnot, during their transition. But I think other times people are really surprised at their response when they do come out to their family and they’re surprisingly supportive.
Keelee MacPhee: Yeah. Yeah. That’s been great to hear those stories. They thought, “Well, I’m going to take this leap and probably going to lose everybody in my church or at work.” Thankfully it hasn’t turned out that way, so that’s pretty awesome.
Erin Everett: It is. It is. With all that in mind too, when it comes to vaginoplasty for the older adult wanting to pursue that, are there any additional challenges that you might face or is recovery time any different?
Keelee MacPhee: Sure. Well, anybody who takes on a vaginoplasty, I talk extensively about the post-operative vaginal dilation process. Because for a year after that surgery, they’re going to be spending a ton of their time and effort with doing the vaginal dilation, that’s for anybody who takes it on. The science behind that is that it takes about a year for scars to fully mature. The vaginal dilation is fighting the natural process of the body trying to close down this track that we’ve created. For my more mature patients, if they have had BPH, so benign prostatic hypertrophy, oftentimes that is relieved by them taking their estrogen, but not all the time. Sometimes they have a little more challenges with urination and that’s not necessarily from the vaginoplasty, but still from their prostates, because their prostate is not removed during the surgery. That’s a possibility.
Keelee MacPhee: Also, sometimes in cases where some more mature women will need to go back on a little bit of testosterone to fully climax. I always tell people this, cis women of a certain age sometimes need to go on testosterone to help them with climaxing. When they’re older, they’ve had some vascular disease potentially, or they’re taking antidepressant medications, there’s a lot that comes into play with the sexual functioning. That’s something that I make people aware of before they have the surgery too.
Erin Everett: Yeah. Yeah. I think that’s really helpful, and especially with your mentioning of the topical testosterone or even, I don’t actually know if you’ve mentioned the route that it would be administered, but typically I prescribe the topical testosterone in those situations to help with climax because the serum levels don’t get so high that they have to worry about any kind of masculinizing effects.
Keelee MacPhee: Right. Exactly. That’s what people are afraid of.
Erin Everett: Yeah. Right. But if I can usually get them to a serum level of about 70, you definitely see an increase in sexual function without any kind of hair growth or anything like that.
Keelee MacPhee: Nice. Oh, that’s great.
Erin Everett: Yeah, and then the other thing that I do often for those patients is give tadalafil five milligrams daily, but I have found that it just really helps with blood flow and they can then have more sensation in their new clitoris, anecdotally it’s been helpful.
Keelee MacPhee: Oh, that’s cool.
Erin Everett: Yeah. Some of these medications do get continued postoperatively but it does function to help with sexual function. Okay. Other questions, diverting away from vaginoplasty, would be, do you offer any options for patients identifying as non-binary or do you have any suggestions for them?
Keelee MacPhee: Oh, well we definitely do. The most common presentation for non-binary is still masculine. So masculinization procedures, so top surgery is what we most commonly see. However, for male to non-binary is oftentimes looking for some sort of genital reconstruction. People have mentioned things like vaginoplasty with penile preservation or gender nullification surgery. These are things that I have not done yet, and it depends on several things coming from the patient, what their goals are. I have discussed these in depth with patients that are considering these options, and we would just have to explore things like, for a gender nullification procedure, which means their penis, scrotum, testicles are removed and they don’t opt for a vaginoplasty. Then what are we going to do for their urinary system, their lower urinary tract?
Keelee MacPhee: That question is very important because there are procedures that could actually make their long-term urinary tract functioning become a problem. Like I’ve explored with patients, whether or not they want to have their urine system drained towards the back, meaning just towards right in front of the anus, versus something that’s more anterior and upfront. Those are the questions that I explore with patients to see, what are we going to work out for your new anatomy, and what’s going to make you most comfortable? You’ve heard about these options too I imagine, right?
Erin Everett: Yeah, yeah. Less so the one that you just described, more so the penile-preserving vaginoplasty has been more of a topic of discussion with my patients.
Keelee MacPhee: Right. Now, that one actually seems easier in my mind to be able to perform because you still have your safety of the urethra within the penis. Then that doesn’t put you at risk of having long-term urinary problems. Similar to the vaginoplasty, if we shorten the urethra and the gender nullification procedure, then the urinary emptying would be coming right through regular skin, and that’s a lot more difficult to manage because according to urology reports, the opening can constrict down so then you have difficulty emptying the urine or the urethra can shorten and so it pulls back up in towards the bladder. These are the things that I want to avoid and not have my patient experience. Even though we may be able to satisfy them as far as their genital dysphoria is concerned, I don’t want to cause more problems.
Erin Everett: Right. More health complications and things.
Keelee MacPhee: Correct.
Erin Everett: Yeah.
Keelee MacPhee: Right.
Erin Everett: Yeah.
Keelee MacPhee: We’re still exploring that. I’m willing to do whatever I can to help with patients who are pursuing these options.
Erin Everett: Yeah. I think that’s awesome. Just to clarify too, I guess, with the gender nullification, just in talks of it, for someone who is assigned male at birth, that still would not impede sexual function via the prostate.
Keelee MacPhee: That’s true. Exactly. I would not be able to remove a prostate, that would definitely be put in the hands of urology. But you’re correct in that sense, that would still be an option for that person.
Erin Everett: Yeah, that’s cool. Yeah, I think that penile vaginoplasty is a very interesting concept. I’m not a surgeon, but a lot of my patients are excited about it because they don’t have a ton of genital dysphoria, but they do want to have penetrative intercourse, it’s not through the anal area. I think that one is super fascinating and could be really cool.
Keelee MacPhee: I agree. I think that would be a fun procedure for me to do because I love doing the vaginoplasty too. But adding in extra layers of consideration for the different incisions we may make that sort of thing. It’s really creative and that’s one of the reasons why I love to do what I get to do because…
Erin Everett: It’s like a work of art.
Keelee MacPhee: Yeah, exactly.
Erin Everett: It really is. Yeah, I mean, because I have talked about how would that look? I guess it depends on the surgeon, but you could also, and the patient what they desire potentially build out, still have a labia around the phallus.
Keelee MacPhee: Definitely. Yes.
Erin Everett: Yeah. That’d be cool.
Keelee MacPhee: Right. There’s a lot of possibilities. I contemplated with another patient whether or not we were going to just shorten their penis and still leave some of it, but move it into a position where it would be lower and embedded within the labia. Yeah, there’s a lot of possibilities for sure.
Erin Everett: For sure. Well, and just to touch, too, a little bit more on your masculinization procedures, which consists mainly of just top surgery, is that right?
Keelee MacPhee: It is usually, yes. I mean there are other features of body contouring that I don’t do that much of, but it all exists.
Erin Everett: Yeah. But you’re not currently performing metoidioplasty or phalloplasty, is that correct?
Keelee MacPhee: That is correct. I’ve been asked to do it mainly for patients who didn’t have insurance and I’d be able to offer a lower price. But since I have never done it, and since these are surgeries that have lots of known complications, I recommend people go to somebody who’s done as many as possible. You want somebody who’s done a lot of these surgeries, not me being the first time sort of thing. I’ve considered it, but I really, really think people are better off going to somebody who’s done more. Fortunately there’s not a lot of people who’ve done a lot of them and even in the best of hands, there’s going to potentially be problems with a stricture or a fistula. But even so, I think going to somebody who’s done a lot of them would be the best answer for everybody.
Erin Everett: Yeah. I’ve heard with those types of procedures, it’s not a matter of if there will be a complication, it’s a matter of when and what type it will be and how to manage it. Just because of the nature of the surgery.
Keelee MacPhee: Yeah. I think you’re right.
Erin Everett: Yeah. But with the top surgery, how do you normally approach that as far as chest size? What can patients expect? Because I have a lot asking about the periareolar versus the bilateral mastectomy. Do you have a preference or an opinion on those?
Keelee MacPhee: Oh, I have an opinion, but it’s patient-guided again. I’m always starting off asking patients, “Okay, what is your goal? What do you want your chest to look like? Do you want to preserve nipple sensation? Is it the contour? Is it hiding the scars?” We talk at length about what they want their chest to look like. In my hands I think that I can achieve the best-looking masculine contour and best looking scars with a bilateral mastectomy and then nipple grafts. People refer to that as the double incision.
Keelee MacPhee: I have done lots of the periareolar incisions even on somebody who’s super small-breasted and I’m always dissatisfied with the final scarring results. It can be touched up, but I tend to feel like, we’re going to potentially have to do another stage of some scar revision to make it look as good as possible with… the areolar scar often tends to widen because it’s under tension and it often can have rippling in it that doesn’t smooth out as nicely as the scars that we get when we’re putting them in the shadowed bottom of the pec major muscle.
Erin Everett: Right. Yeah, I noticed that on your website. I was looking through a lot of the pictures of your post-op and I was really impressed because I do feel like sometimes after the bilateral mastectomy, the scars are very abrasive, they’re very obvious. I’ve found, I mean, I’m not a surgeon, again, but I don’t know what differs from your technique to other surgeons, but that your scars were much well-hidden and far less obvious. I thought that was really cool.
Keelee MacPhee: Well, thanks. I appreciate that. I think that even though a lot of people focus on the scars, I can promise you that they’re going to fade and be hard to see over time. I know the scars are very important and we do a lot of meticulous sewing to get them to look good. I’m actually more concerned in many ways about the position of where they are and the contour of the chest more than anything. Then I can’t forget to mention this is that I take out all the breast tissue so that patients don’t have to be concerned about mammograms down the road and potential breast cancer. That does influence if patients have family histories of breast cancer when they talk with me. I don’t want somebody to be left with breast tissue if they have a strong family history of breast cancer and then are going to be faced with as a trans man down the road trying to get mammograms. That’s a challenge.
Erin Everett: Right, right. Yeah, that’s uncomfortable. I mean, I like that approach. Why even worry about it?
Keelee MacPhee: Yeah. Right.
Erin Everett: Yeah. That’s awesome.
Keelee MacPhee: But if people told me, “Oh, I want to keep my nipple sensation,” then we’re going to be doing a reduction rather than a mastectomy. They’re going to have to keep some of their breast issue, which is in a cone around the main nerve to the nipple. That resulting contour is not so masculine at all. But then they’ll be able to preserve nipple sensation. It’s all individualized. I always tell people there’s possibilities. Whatever you’re dreaming of, let me know and I’ll give you the options-
Erin Everett: I love that.
Keelee MacPhee: … to go from there. Yeah, its nice. Because then it’s not in my hands, it’s in the patient’s hands. They get to make their decision for themselves, and that’s always much more comfortable for me.
Erin Everett: Yeah. I love that because that’s how I practice as well. Patients come to me and when we’re talking about hormones, it’s like, “Well, as long as you don’t go above what I recommend, because that could be harmful. You’re really in full control of your dosing and what kind of results you’re going to get.” It’s very individualized-
Keelee MacPhee: That’s True.
Erin Everett: Yeah. I don’t believe in cookie cutter medicine. Yeah, that’s awesome.
Keelee MacPhee: Why are we like that and others are not is my question. Why do you think you have a comfort in practicing that way, whereas in my field I have colleagues that just tell the patient what they’re going to get?
Erin Everett: Yeah. That’s a really good question. I don’t know. I don’t know if it’s interpersonal skill or just willing to meet people where they’re at. I don’t know. What do you think that is?
Keelee MacPhee: Well, listening to you, I would say it’s a level of confidence that you are comfortable in knowing what’s safe and what’s best for your patient and being able to guide them to whatever they’re seeking yet making it safe for them. I think I’m the same way. If it were unsafe, I would tell them.
Erin Everett: Yeah, I definitely give them their limits like, “Okay, well.” Yeah. No, I agree with you. No, that one, because patients will often ask if they can go up on their T dose and that’s a simple answer. Above what I normally recommend as the higher limit, no, because you’re going to have negative outcomes. You’re not going to masculinize any faster and it’s going to decrease estrogen and you might start bleeding again. But below that, yeah. I think, to your point, it is a certain level of confidence and experience.
Keelee MacPhee: Then actually, we’re working with this broad range of individuals. If you try to… can you imagine trying to tell every single one of our patients this is the same thing for each one right after that. That just doesn’t make any sense when they’re approaching us from so many different backgrounds and that sort of thing. It’s nice to have the variability.
Erin Everett: I agree. It sounds ludicrous, but unfortunately people are still doing it. Hopefully again, with a wave of change, we’ll see more providers like ourselves.
Keelee MacPhee: Yeah.
Erin Everett: That’s awesome. Well, it’s been super great chatting with you today about all the services that you offer and your approach to care. I think it’s wonderful and I think a lot of my patients are going to want to receive care from you.
Keelee MacPhee: Thank you very much. It’s really nice to get to talk to you in person. This year has been crazy with COVID and I have not had so many fun interactions with people as I used to. But thank you so much for reaching out to me. Clearly we both have strong feelings about this community that we get to help and work with. It’s really wonderful to get to know other people that are also passionate and great providers for the patients.
Erin Everett: Awesome. I appreciate that. Yeah, no, I’m very excited. To your point, aside from everything that I’ve been able to do with the podcast, you’re right, it has been hard this year so this is really rewarding. I really enjoy connecting with people like yourself.
Keelee MacPhee: Awesome. That’s great. Well, keep it going. I hope that you get a lot of traffic for you helping people and expanding knowledge. It’s awesome.
Erin Everett: Yeah, I really do. Actually, quite a few listeners from this, the established care, will reach out and ask about providers in the area and things like that. But since we are doing telemedicine, a lot of people have reached out and said, “Hey, I listen to your podcast and I want to get started.”
Keelee MacPhee: Nice.
Erin Everett: Yeah, so that’s really good. But also, I mean, the reason why I started it was just to really play MythBusters. As you know, these people don’t have a lot of really good, reliable resources to find information. For them to be able to hear from you without having to have the courage to reach out to your office first and to hear what you’re all about, just adds more confidence to them to be able to go and say, “Okay, well I want to reach out to Dr. MacPhee for my top surgery or my vaginoplasty.” It helps a lot. They realize that you’re a real person and you’re not just a figure on your website.
Keelee MacPhee: Right, right. Yeah. I always like that sort of rapport to be growing and for somebody to hopefully be comfortable with me when they meet me.
Erin Everett: Yeah. Well, I find you very easy to talk to, so I’m sure patients have the same experience.
Keelee MacPhee: Oh, thank you. Appreciate it. Yeah.
Erin Everett: Awesome. Remember everybody, stay fierce and live your truth.
In episode twenty-two of Exclusively Inclusive, Erin Everett, NP-C, interviews transgender plastic surgeon Dr. Keelee MacPhee. Double board certified by the American Board of Plastic Surgery and the American Society of Plastic Surgery, Dr. MacPhee performs transgender surgeries primarily at the Duke Regional Hospital in Durham, NC.
During the episode, the two discuss Dr. Keelee MacPhee’s background as a cosmetic plastic surgeon and how her career evolved into specializing in transgender plastic surgery to help her patients become more confident and comfortable in their bodies. Dr. MacPhee highlights her affinity for rhinoplasty and facial feminization surgeries, as well as how she assists her patients in receiving preauthorization and maximum reimbursement from their insurance providers for the transgender surgical procedures she performs.
Furthering the insurance coverage discussion, Dr. MacPhee talks about how most insurance companies follow the WPATH standards of care (which they both believe to be outdated) when determining eligibility of coverage. This typically requires at least two mental health provider support letters affirming the patient has been living full time as their gender and/or have been undergoing hormone replacement therapy for at least a year. When insurance is not available, Dr. MacPhee uses the informed consent model and does not require mental health letters.
Later in the episode Erin and Dr. MacPhee discuss the emergence of older adults who begin their transition much later in life and the considerations for those patients when undergoing transgender or gender affirming surgeries. Dr. MacPhee explains her approach to patient education for vaginoplasty and the importance of dilation exercises for at least one year after surgery, as well as the need for transgender women to receive testosterone post-op to assist with sexual climax. Erin adds that the use of Tadalafil also helps promote sensation in the new clitoris post-vaginoplasty.
Further in the episode, the two discuss penile preservation vaginoplasty, as well as gender nullification surgery — the removal of the scrotum, testicles, and penis, but the patient does not opt to have vaginoplasty — and the need to re-route their urinary function and the associated health complications.
Rounding out the episode, Dr. Keelee MacPhee covers FtM breast surgery and how she determines what the best top procedure will be based on the patient’s ultimate goal for transition. Factors that come into play are the desire to preserve nipple sensation, breast contour, hiding of scars, etc. While Dr. MacPhee has done numerous periareolar procedures, she does suggest that bilateral mastectomy with nipple grafts typically provides the best results for FtM chest masculinization.