Eyelid
Combined upper and lower eyelid surgery in one session — the most complete periorbital rejuvenation when both lids need treatment.
Medically reviewed by Ronald W. Kristan, MD, FACSOculoplastic SurgeonLast updated June 2026
Part of our complete guide to Blepharoplasty (Eyelid Surgery) — this page covers four-lid blepharoplasty in depth.
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.
A combined approach makes sense when:
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.
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Skin incision is marked within the crease of the eyelid
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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.
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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. Kristan or emergency care. See Blepharoplasty Recovery for the day-by-day course.
Schedule a consultation with Ronald W. Kristan, MD, FACS to learn if this procedure is right for you.
