Objective To explore the effect of four-step eye bag plastic surgery on ocular plastic effect and ocular symptoms in middle-aged and elderly patients with ocular plastic surgery. Methods A total of 118 middle-aged and elderly patients who received ocular plastic surgery in the Department of Medical Aesthetics, Shaoxing Maternity and Child Health Care Hospital from February 2022 to January 2024 were selected as the research subjects. According to different surgical treatment methods, they were divided into the control group and the observation group, with 59 patients in each group. The control group received lower eyelid skin approach eye bag plastic surgery, and the observation group received four-step eye bag plastic surgery. The ocular plastic efffcacy, ocular symptoms, periorbital repair effect and complication rate were compared between the two groups. Results The total effective rate of the observation group (96.61%) was higher than that of the control group (79.66%) (P<0.05). After treatment, the scores of lower eyelid skin laxity, ptosis and bulkiness in the observation group were lower than those in the control group (P<0.05). At 20 days after treatment, the scores of eye bags, wrinkle area, skin glossiness and tightness in the observation group were higher than those in the control group (P<0.05). The incidence of complications in the observation group (1.69%) was lower than that in the control group (18.64%) (P<0.05). Conclusion Four-step eye bag plastic surgery for middle-aged and elderly patients with ocular plastic surgery can effectively improve the effect of eye bag plastic surgery, relieve lower eyelid laxity, ptosis and bulkiness, and has high safety.