Old friends Sean (the family man) and Christian (the playboy) are partners in a plastic surgery office. Their relationship is under fire after Christian operates on a Colombian drug lord who pays him in drug money. Sean's family life is also in upheaval, and he is headed for a mid-life crisis.

Twin sisters want plastic surgery done to look different from each other. Sean moves out so he can experience life as a single man. Matt decides to try and perform a circumcision on himself after his girlfriend sees his penis. Christian is plagued with thoughts of Julia.

Christian learns that Kimber and Merril are engaged. Escobar continues to have the surgeons do things for him. Liz is sent to Bermuda after being shot in the leg by one of Escobar's people. Sean goes to kill Escobar. Escobar makes a deal with Sean; a new face for their freedom. Christian learns, in the delivery room, that he is not the father of Gina's baby. Julia returns to get the paternity test she had done a while ago. The doctors do surgery on Escobar, and give him the face of a criminal even higher than Gallardo on the Most Wanted List - Armand Ortiz. Ortiz is arrested at the airport for bank robbing and killing a federal agent.

Sean has just turned 40, and he is already noticing it. His body is aging, and he has developed "the yips", making his performance during surgeries decline. Julia breaks the news to Sean that her mother, Erica, is coming to visit. Erica tells them that she wants a facelift - and she wants Sean to do it. Sean would prefer that Christian do it instead. Meanwhile, Christian is having problems with picky Gina, who is trying to keep Christian away from baby Wilbur, because it isn't his baby. Having his own problems with age, he is rejected by a 25-year old at a bar. Christian decides to hire a nanny, who he ends up having sex with, and later learns that she is giving the baby drugs to keep it from crying. Christian tries to convince Sean to have botox, but he refuses (at first). They perform surgery on a woman who was shot in the face nine months earlier. She is brought along by her gay friend. The two are having problems because the woman loves Chad, but Chad doesn't love her in that way, because he's in love with his boyfriend. We learn that Chad and the woman were planning on shooting each other, but she couldn't pull the trigger, so Chad was left unharmed.

During Erica's facelift, Sean panics and can't do it. Christian is having some trouble too - he's slept with Erica, the night of Sean and Julia's wedding. The surgery continues. Later that day, Christian is having problems with Wilbur, so he calls Julia to come help him. She gets upset on how Christian can't handle his own responsibilities, and snaps at him for sleeping with her mother.

Joan Rivers consults with Sean and Christian to have all of her plastic surgeries undone, because she wants her grandson Cooper to learn that you don't have to be perfect. When she ultimately learns what she will turn out like after the work has been finished, she decides to give up on her original plan and asks the doctors to schedule her for a facelift the next morning. Matt is concerned about Ava, who seems obviously depressed. He suggests they go away to Paris and start a new life together, which she reluctantly accepts after some convincing. Matt goes to McNamara-Troy to steal drugs for her to take with them. Christian finds him, and gets upset when he learns Matt is going to Paris. Christian goes to have a talk with Ava, and when trying to make a point using sex, he learns that Ava is really a transsexual. Julia, Sean, and Christian spend the night researching, and trace their way to Maryland and a Gender Reassignment center.

The Carver strikes at a sorority house. His identity is revealed. Ariel's dad kidnaps Matt and Cherry. Ariel's dad forces Matt to make a life threatening decision, while the carver tries desperately to get his last minute revenge. Julia discovers that there might be something wrong with her baby.

Sean and Christian may be celebrating a milestone surgery, but it looks like the future of McNamara/Troy is in jeopardy. Julia tells Sean some devastating news about the baby. Christian decides to redecorate his apartment after a disturbing appointment with his psychiatrist.

Sean considers selling his shares of the practice to Christian and Michelle, although Michelle's past starts to threaten her future with Christian. Meanwhile, Escobar's wife needs cosmetic surgery.