Saggy lower butt - how can I fix this without big scars? (Photos)

Hi MLI2,
Thank you for your question regarding your saggy lower butt and how you can fix this without big scars. Thank you for your history and pictures. A consultation would be mandatory before any surgery could be suggested. However, based on your history and pictures, a posterior butt lift would be your best procedure. Let’s analyze your picture. You have cutis pleonasmus (excess skin) and dermatocholosis (loose skin) of your buttocks. You do not have lipodystrophy (excess fat) in your buttocks. Your buttock shape looks good; it's just the extra skin at the bottom of your buttocks. The only way to remove excess buttock skin is with an incision. There are many types of butt lifts. However, based on your pictures, most plastic surgeons would recommend a crescent or infra-gluteal roll approach. An infra-gluteal (in the lower buttock fold) butt lift is performed under general anesthesia and takes about 3 to 4 hours to complete. The incision extends from the lateral thigh, where the thigh meets the bottom of the buttock. Then the incision extends in a gentle curve under the buttock towards the groin. Tissue dissection is carried up on the buttock. The lower buttock rolls are thus eliminated. Usually, drains are not needed. Allow yourself a 3- to 4-week recovery. During the recovery, it will be important for you not to flex your lower back or bend over. Good luck. Seek an experienced, board-certified plastic surgeon with significant experience in the posterior buttock lift or butt lift. Make sure they have performed many butt lift procedures and have the before-and-after pictures to prove it. Carefully examine their before-and-after photos and review their RealSelf profile.  
If you cannot find an experienced plastic surgeon in your neighborhood, consider traveling out of state. Sincerely, Dr. Katzen. ( Plastic Surgeon, President of the American Society of Bariatric Surgeons, certified by the American Board of Plastic Surgery, Fellow of the International Society of Aesthetic Plastic Surgery, American College of Surgery, and International College of Surgery and ​member of the American Society of Plastic Surgery, American Academy of Cosmetic Surgery, RealSelf Hall of Fame, and RealSelf Doctor Advisory Board for Medical Review and Consumer Panel.)

Allow me to answer your question as best i can based upon your photo. However, please keep in mind that an in-person, or at least a virtual, consultation with physical exam is first necessary before any legitimate evaluation or final surgical recommendations can be made.

Buttock “sagging” is usually a combination of loss of volume or deflation (after weight loss, liposuction, or post-BBL) and/or the effect of aging and gravity. Unfortunately, neither fat transfer or minimally invasive procedures such as J-plasma, radiofrequency, ultrasound, or lasers work effectively in this area. So, I personally first treat patients like you by restoring volume to the buttock with a buttock implant. This will create a more desirable smooth and rounded perky buttock profile. If not adding volume with an implant, the buttock will most certainly always appear more flat with just a buttock lift from above. A lower buttock tuck is usually then performed at six months following implants. Coincidentally, a lower buttock tuck also doubles as a thigh lift. In this sequence, the implants have fully settled into final position so that any remaining loose skin can be most accurately identified and removed with the lower buttock tuck. Please note, because an extremely few number of board certified plastic surgeons specialize in buttock implants, you may have to travel away from your local area to seek consultation with this particular type of surgeon. Getting it done right the first time around is not only the best chance for success, but also will save you from a lot of headaches and money in the future. Glad to help.