Balanced reciprocal translocations are frequent chromosomal rearrangements between two nonhomologous chromosomes with an approximate incidence of 1/500 and can be inherited or de novo. Individuals carrying these rearrangements are usually phenotypically normal but with increased risk for infertility, miscarriages, stillbirths, and abnormal liveborn offspring. More complex rearrangements such as double reciprocal, triple reciprocal, and three-way balanced translocations are rare events. Complex constitutional rearrangements involving more than three chromosomes are extremely rare and a recent review of the literature described less than 15 patients. We report here a one-day-old full-term female with prominent labial folds and enlarged clitoris that was referred for cytogenetic analysis. Chromosome studies demonstrated the appearance of either two reciprocal translocations or a single four-way translocation. Metaphase FISH and SNP microarray analyses were performed on the patient to determine the complexity of the rearrangement. FISH analysis confirmed the presence of a four-way translocation without deletions or duplications at the breakpoints as determined by SNP array. Further, the SNP array detected a 4.5 Mb deletion of 1p31.1 and a triplication of 1q43 characterized as a variant of unknown significance (VUS). Parental peripheral blood has been requested to determine the origin of the rearrangement, the 1p31.1 deletion, and the 1q34 VUS and these results will be presented accordingly.