Pre- and post-operative body image, self-confidence and individual and family adjustment were compared in 250 patients (aged 6 weeks to 39 years) with severe craniofacial deformities. Major congenital deformities of genetic or idiopathic etiology were present in 178 patients and 72 had tumours or other late-onset deformities. The patients and/or parents were interviewed by a child psychiatrist and a social worker as part of the routine pre-operative assessment. In addition to a semistructured interview protocol, the patients and parents were asked to rate the deformity according to Hay's Scale and, when appropriate, to complete the Piers-Harris Self-esteem Inventory. One and two year post-operative reevaluations followed the same protocol. The results indicated that the age of the patient, pre-operative expectations and origin of the decision for surgery (particularly in adolescents) are the most significant predictive factors of post-operative psychosocial improvement.