In the fourth season premiere, Sean and Christian celebrate a milestone surgery and receive an interesting proposition from patient Burt Landau , a wealthy medical venture capitalist who wants bigger testicular implants, and his much younger wife, Michelle. Meanwhile, Julie reveals devastating news about her unborn child to Sean, leaving him full of fear and doubt. Phone sex operator Cindy Plumb (KATHLEEN TURNER) requests that the surgeons make her voice more youthful

EPISODE 2: BLU MONDAE Sean and Julia make an important decision about their unborn baby. After getting into trouble with their new boss, Sean and Christian discover the drawbacks of no longer owning their practice. Matt's decision to go down a new path in life is met with uncertainty by his family.

Sean and Julia interview a possible nanny. They both like her a lot. Sean got a hybrid car. Christian goes to the gym and is envious of another plastic surgeon there who's in much better shape than he is. Christian encounters a changed Matt in the gym.

Shari Noble comes in with one of her nipples bitten off, apparently by her dog. She wants it reconstructed before her husband returns from Iraq. Christian goes to a lesbian bar with Liz, where he tries to attract the attention of a woman but she’s attracted to Liz instead. Sean and Christian meet with a kidney specialist for a patient of theirs. Julia talks with a breast-feeding expert.

A lottery winner wants Christian to perform extensive plastic surgery on her---and her husband and daughter. Christian does so, and more. He can certainly use the money because James is blackmailing him over his affair with Michelle. Elsewhere, Christian and Sean try to win Matt’s affection with a Porsche, but he’s leaning toward Kimber and Scientology; and Sean buys an engagement ring for Julia.

Sean worries that Monica (Jennifer Hall) is insane, until help arrives in an unexpected form. Christian's therapist reveals that she is a diagnosed sexual compulsive, and their sexual encounter on her desk has proved that she is not yet cured. She requests that a sadomasochistic tattoo be surgically removed from her lower back. The affair between Christian and Michelle (Sanaa Lathan) is exposed. Guest starring Peter Dinklage, Robert LaSardo and Larry Hagman.

Liz collapses at work, because her sole kidney is only working at 10% anymore. Christian and Sean are going to take the test if they can donate one of their kidneys. Burt Landau wants a re-constructive surgery for his face after a stroke caused by the side effects from Viagra.

Even Christian is startled when his extremely rich, spoiled and vain client Mrs. Hedda Grubman announces she's going to die from terminal lung cancer but wants him to be the last to touch her, in bed hopefully, but also as a posthumous patient to make her the best-looking funeral star ever. Conor's upcoming hand operation makes Sean so nervous he beats up an offensive boy's father.

And Sean offers a surgical consultation to Marlowe, who comes to McNamara/Troy hoping for a leg-lengthening procedure in order to impress the woman he loves. Recurring guest star LARRY HAGMAN appears as Burt Landau. Liz gets surgery to look better for her girlfriend (ALANIS MORISSETTE). James uses Christian to lure Michelle into stealing another kidney. Marlowe wants his legs lengthened.

Merrill Bobolit returns, knowing some very interesting information about Sean and Christian. This information leads back to crime lord Escobar Gallarado, who blackmails the surgeons into repairing his burned face. Sean confronts Marlowe, and the truth flows from everyone, including Matt, who's news shocks everyone.

The episode starts out with Conor, now at 20, having a discussion with a psycologist. Conor is finally at long last, having his re-constructive surgery on his right hand, in just two days. But before the surgery takes place, Conor wishes to tie up some loose ends of his past, which is why he is seeing a psychologist. Conor decides to organize a family dinner so that everyone may meet the surgeon that will be performing his surgery, even though, he explains, the family is not close. Conor states that Julia and Sean have separated, Matt is almost never around, and Annie feels as if she was neglected as a child, and resents Julia. Nevertheless, the family meets at a diner. Sean almost decides to leave once he sees that Julia is at the dinner, but is soon convinced by Christian (who is also attending the dinner, and who appears to still be the playboy he was 20 years ago), and Conor to stay. Soon after, Matt arrives. Conor reveals that Matt, now a surgeon like his fathers, will be the one performing the surgery. Sean is disappointed that he was not asked to perform the surgery, but tries to hide his emotions. Meanwhile, back in 2006, Sean and Julia's marriage is falling apart once again.

Christian proposes to Michelle even though he doubts his ability to maintain a long-term relationship; a lonely Sean takes a morbid case for reasons that have as much to do with himself as with the patient; and James wants to use the McNamara-Troy OR for her own operations.

Sean drinks heavily as he spends a gloomy Christmas without his family; Christian receives an unexpected gift when a 3-year-old Wilbur comes back into his life; and James forces Michelle to help as she takes drastic measures to fill her holiday kidney quota.

Just as Christian and Michelle begin legal proceedings to adopt Wilber, Gina returns, claiming to have turned over a new leaf. Sean operates on a puppet master who wants to look like his puppet. Matt turns to Kimber's former friends in the porn industry to spice up their sex life. Liz ends her relationship with Poppy (Alanis Morissette).

Sean announces his plans to sell his share of McNamara/Troy to Christian and Michelle (Sanaa Lathan) and leave for Los Angeles. Escobar Gallardo is back, and requests surgery for his scarred wife. Michelle, threatened by Escobar for her part in the organ harvesting ring, is forced to come clean to Christian, driving them apart in the process.