I think you are finding out why many surgeons do not like or do this operation. The lower incision will not lift your buttocks. This is not mechanically possible. Secondly, these incisions almost always migrate lower than where they started and as a rule are very unsightly. However, if you are willing to accept the scars and have significant laxity of your posterior and lateral thighs( these are areas treated with this incision/procedure) then proceed with caution and be sure your surgeon has experience with this particular surgery.
Body lift with scar at buttock crease
This is the classic Pitanguy operation. It has largely been replaced by more modern procedures, as it had several problems. It tended to flatten the curve of the buttock, and the scar tended to drift out of the buttock crease, onto the back of the thigh, where they could be quite visible. Painful scars could make sitting difficult.
Modern lower body lifts do a better job of lifting the buttock, and placing the scar where it will be concealed by underwear or swimsuits.
That being said, sometimes, even after a well-performed LBL, a few patients will have some skin redundancy in the buttock crease area, and may benefit from a skin excision there.
Lower body lift with incision under the buttocks
To lift anything the force has to be exerted directly over it. You could NOT lift the buttock with incisions under it - BUT you could lift the posterior thigh. As a matter of fact, in the infancy of Plastic Surgery this operation was popularized by the famous Brazilian Plastic surgeon Ivo Pitanguy.
The trouble was that the scars with such posterior thigh lift migrated lower, flattened the lower buttock, were associated in some cases with injuries to the Sciatic nerve which comes out under the edge of the buttocks, among other complications. As a result, it is rarely done today, except for when the patient fully understands the risks.
In your case "I tried it with an incision in the belt line, skin undermined, etc, but excess butt and thigh skin was not addressed." I suspect that you had a relapse of skin laxity which is not uncommon with people who lose a lot of weight and have damaged skin. A revision procedure may correct your deformity.
Take careful understanding of Secondary buttock thigh lift
There are several reasons why plastic surgeons shy away from buttock lifts. The first is that in most cases the belt line lift procedures will lift and contour the buttock and the side of the thigh. We get all that we need out of the single procedure.
The second reason is that additional surgery or secondary procedures as we call them are indeed more difficult. The results may not be as predictable or satisfactory to our patients, and therefor require careful consideration and understanding. No patient or surgeon will likely take them on without caution.
Secondary buttock thigh lift involves the lower incision you mention across the lower fold of the buttock. The risk can include dents and depressions, scar asymmetry, a flattened buttock, and scar widening or descent or a pulling lower of the scar. In the healing period patients cannot sit fully for up to four weeks to avoid tension on the suture line. Despite all the drawbacks the procedure has been gratifying to patients.
I suggest you seek a plastic surgeon with experience and excellent judgement who will be with you throughout. You should understand your procedure well to avoid disappointments. It is an accepted procedure though, and might be what you are looking for.
Best of luck.
I understand your concerns with your outcome from your prior surgery, and that you would like to achieve more tightening of the buttocks and thighs. I'm not sure I agree with you that this would only be possible through the more radical approach you describe though, as the traditional approach to body lifting is usually extremely successful in addressing these areas, even in patients with extreme amounts of loose, stretchy skin.
In addition to probably not being necessary to achieve your goals, the approach you describe would put you at high risk of having a scar that creates long term discomfort when you sit, and the greater potential for injury to your Sciatic Nerve (one of the largest and most important nerves in the body); that's why you haven't been able to find a surgeon who would do this. I would return to your original surgeon and review this with them. See if a revision might make you happier.
Lower body lift incision under buttocks
I consider thispart of a posterior thigh lift, vs a lower body lift. It is sometimes hard to hide this incision right in the crease below the buttocks, sometimes the incision will extend too far laterally and is hard to hide and it can flatten the buttocks, which most women don't care for. Ultimately in all massive weight loss reconstruction, the patient is trading shape for scar.
I am affraid that there are many surgeons who are calling a circunferentiaol tummy tuck, a lower body lift. These use the smae incision but are not the same. A lower body lift in my practice has the following componenets: circumferential tummy tuck, buttock lift, formal outer thigh lift, thigh lift in front, and correction of pubic laxity. Most patients will also want a buttock augmentation at the same time. Like many patients who I have seen recently, you will need a lower body lift revision. See my gallery for more information.
Incision: visibility vs effectiveness
on occasion I will place an incision in an "atypical" location such as you described. It may result in a more predictable result for a recurrent problem or challenging area. All weight loss patients are different so the operation and incision location must be tailored to the individual patient needs.
An incision at the bottom of the buttocks (in the fold) can frequently be used for contouring of hanging skin at the lower portion of the buttocks. However, this does not truly constitute a lower body lift, as it does not lift the lower body skin.
This is what I call a posterior thigh lift. It works very well to tighten and lift the posterior and lateral thighs. It can also be extended to the medial thigh. It will not "lift" anything above it, but rather will pull down on it.