The distinguishing feature of this approach is the lack of a skin incision. 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. A topical anesthetic is applied to the eye, a corneal shield may be applied to protect the cornea. A cut is made in the depth of the conjunctival sac or the fornix. Dr. Gerzenshtein prefers this approach to the approach that uses a more superior incision, for multiple reasons. Through stab incisions in the capsulopalpebral fascia fat is removed under direct vision, checking constantly for symmetry and any bulging still remaining. Typically, no suturing is required, as the puncture sites heal within a day. If mild to moderate skin laxity is present, carbon dioxide laser resurfacing is added to the lower lids.