Can pocket tightening be done instead of mesh to help the implant stay up?

Pocket contouring is a reasonable approach to try to improve implant positioning whether it is lateral malposition or inferior malposition or even medial malposition. The problem with just pocket contouring without reinforcement (mesh) is that the correction will likely not be long term and you will end up requiring further surgery. Nowadays, we do something called thermal capsulorrhaphy (AKA popcorning) as opposed to sutures as the sutures typically don’t last and oftentimes pull through the weakened tissues thus losing the repair. The long term results of just pocket contouring are not adequate, and therefore, depending on the severity of your malposition, I would likely recommend use of a supportive scaffold to maintain your results.

Dear Sarapowerfull12,
it is hard to tell for sure without an examination. Sometimes, pockets can be tightened in order to keep the implant in the desired position. If you are considering surgery, I would suggest you consult a board-certified plastic surgeon. Only after a thorough examination, you will get more information and recommendations.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

If you have an established capsule, and there is no need to remove it (like capsular contracture), then it is definitely possible to use cautery and/or sutures to reposition the implant. I started using this technique in 2013, and the majority of cases are successful without having to use a graft. A graft may be indicated if the tissue is overly weak (lots of stretch marks) or thin. I would recommend seeking a surgeon who is skilled in revision breast surgery since it can be more complicated than initial augmentation.

The pocket will be tightened to help raise the implant. Sometimes, however, the tissue is thin so mesh support is best. Also, you may need to go down to a smaller less heavy implant.

IMO mesh has been highly overused. In my more than 30 years of practice, I have only used it 3 times and that was when it was new and novel. I would only use it today IF your tissues were especially thin or if I had attempted a suture repair that failed - but that hasn't happened for years. My process with obliteration of the excess pocket with cautery, oversewing that with strong dissolvable sutures, holding the repair in place for 3 months 24/7 with an underwire bra I fit to the patients, and avoiding any pec exercise or bouncy exercise for 3 months yeilds in my hands a 99% success without mesh.