BACKGROUND: Transgender women suffer a great deal of self-reported anxiety and concern about their facial appearance as they may readily be identified by observers as "trans" when they would prefer to be interpreted solely as women. Little is known about the psychological distress that transgender individuals experience in their decision to undergo major aesthetic plastic surgery as a result of their appearance concern. As such, it remains unknown whether transgender individuals experience improved appearance anxiety and a greater quality of life following facial feminization surgery. AIMS: The objective of this study is to determine, using the Derriford Appearance Scale 24, whether any improvement can be seen among transgender patients in their level of appearance anxiety following facial feminization surgery. We also aim to look at whether additional improvements can be seen in the quality of life of transgender patients. METHODS: A prospective study was conducted on patients undergoing facial feminization surgery. The outcome measure used was the Derriford Appearance Scale 24. The Derriford Appearance Scale 24 was given to transgender patients to fill out at the end of their pre-operative visit before their schedule facial feminization surgery. The scale was then also administered three weeks following surgery and three months following surgery, via the Internet. RESULTS: Twenty-four patients were enrolled. Of these, fourteen patients completed at least one of the surveys, post-operatively; twelve patients completed all three surveys. Of those patients who completed at least two out of the three surveys, scores revealed that 85% of transgender patients displayed higher levels of psychological distress when completing the first survey, preoperatively, than in subsequent post-operative surveys. CONCLUSIONS: Transgender individuals enrolled in the study showed decreased levels of distress both three weeks after surgery and three months after surgery. These results were promising in displaying amelioration of appearance anxiety following facial feminization surgery. Though results show increased quality of life, the degree of impact that gender confirming facial features may have on quality of life for transgender patients has yet to be assessed.