Depending on the degree of necessary dissection, and patient comfort with local anesthetic only, the procedure may be done under local or regional block with or without sedation, or under general anesthesia or some variation of it. Marks are made with the patient upright; the transcutaneous approach may be taken through a number of incisions, but most commonly just under the lower lash line. The appropriate anesthesia is then administered, and the superficial eyelid tissues infiltrated with local. The dissection is carried to the septum and further down to as far as the crease on the side of the nasal alae (flaring portion of the nose), this is done in the subperiosteal plane (under the facial bone covering) in patients requiring large correction, and in the superficial plane in patients requiring less correction of the nasal fold or smile lines. The septum is then opened, the fat in question removed or repositioned symmetrically, and the lid tightened horizontally. The previously dissected cheek fat pads are suspended in an elevated position adding bulk to the cheek-bones and improving the smile lines (nasolabial folds). The cheek is suspended securely to the fascial or bony tissues to the outside of the eye, a very conservative extra skin excision is performed, and the incisions closed.