Eyelid
Four-Lid Blepharoplasty
Combined upper and lower eyelid surgery in one session — the most complete periorbital rejuvenation when both lids need treatment.
Medically reviewed by Mark Mazow, MDOculoplastic SurgeonLast updated June 2026
Part of our complete guide to Blepharoplasty (Eyelid Surgery) — this page covers four-lid blepharoplasty in depth.
Four-Lid Blepharoplasty (Combined Upper & Lower)
Four-lid blepharoplasty treats both upper and lower eyelids — all four lids — in a single operative session. When both excess upper-lid skin and lower-lid fat herniation are significant, combining the procedures can provide comprehensive periorbital rejuvenation in appropriately selected patients while sparing the patient a second anesthetic and a second recovery.
Is It Right for You?
A combined approach makes sense when:
- Hooded or heavy upper lids coexist with puffy lower-lid bags
- You want to balance the upper and lower lids in one result rather than staging them
- You are healthy enough for a slightly longer (still outpatient) procedure
Each lid is addressed with its own technique — a hidden crease incision above (see Upper Eyelid Blepharoplasty) and a transconjunctival or sub-ciliary approach below (see Lower Eyelid Blepharoplasty) — combined into one plan.
The Combined Procedure
Blepharoplasty SurgeryStep-by-Step
Blepharoplasty SurgeryStep-by-Step
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Skin incision is marked within the crease of the eyelid
IncisionClosure
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Performed as an outpatient under local anesthesia with sedation, four-lid surgery typically takes one to three hours depending on the techniques used. Upper-lid skin (and any prolapsed fat) is removed through the crease, while lower-lid fat is removed or repositioned and any excess skin is conservatively trimmed. Because both lids heal together, there is a single recovery period.
Before & After
Upper & Lower Blepharoplasty Before & After
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Age 50
Recovery & Risks
Recovery mirrors that of the individual procedures, with swelling and bruising across both lids for 1–2 weeks and a result that stabilizes by about 3 months. The combined risks are those of upper and lower blepharoplasty together — temporary dry eye and lid swelling commonly, lower-lid malposition and (rarely) retrobulbar hemorrhage among the more serious. Retrobulbar hemorrhage is a vision-threatening emergency: sudden severe eye pain, pressure, decreasing vision, or marked eye protrusion after surgery requires immediate contact with Dr. Mazow or emergency care. See Blepharoplasty Recovery for the day-by-day course.
Frequently Asked Questions
- What is four-lid blepharoplasty?
- Surgery on both upper and lower eyelids — all four lids — in a single operative session, combining upper and lower blepharoplasty for complete periorbital rejuvenation.
- Why have all four lids done at once?
- When both upper skin excess and lower-lid fat bags are significant, treating them together balances the result and spares the patient a second anesthetic and a second recovery.
- Is the recovery longer than a single-lid procedure?
- Recovery is similar in length to the individual procedures — swelling and bruising across both lids for 1–2 weeks — because both lids heal during one recovery period.