Eyelid
Combined upper and lower eyelid surgery in one session — the most complete periorbital rejuvenation when both lids need treatment.
Medically reviewed by Christine Annunziata, 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 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. Annunziata or emergency care. See Blepharoplasty Recovery for the day-by-day course.
Your Surgeon
Christine Annunziata, MD
Metrolina Eye
🏅 ASOPRS Fellowship Trained
Schedule a consultation with Christine Annunziata, MD to learn if this procedure is right for you.
