Objective To explore the efficacy and safety of four-step eye bag plastic surgery in elderly patients undergoing ocular plastic surgery. Methods A total of 160 elderly patients who received ocular plastic surgery in the Medical Cosmetology Center of Shaanxi Provincial Institute of Dermatology Hospital from January 2022 to February 2024 were selected and divided into the control group and the observation group by the random number table method, with 80 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 clinical efficacy, ocular symptom scores, complications and treatment satisfaction were compared between the two groups. Results The total effective rate of treatment in the observation group (95.00%) was higher than that in the control group (77.50%) (P <0.05). After treatment, the scores of lower eyelid skin ptosis, relaxation and swelling in the observation group were lower than those in the control group (P <0.05). The incidence of complications in the observation group (2.50%) was lower than that in the control group (20.00%) (P <0.05). The treatment satisfaction in the observation group (90.00%) was higher than that in the control group (75.00%) (P <0.05). Conclusion Four-step eye bag plastic surgery has a better treatment effect in elderly people. It can effectively improve problems such as lower eyelid skin relaxation, ptosis and swelling in patients, reduce the risk of complications, and improve patients' treatment satisfaction.