Bottom of breasts look “pulled down” and sit to the side, lack of upper pole - do I need to replace the implants? (Photos)

Based off your photos and the comparison photo - yes, does appear that the reverse TT incision pulled down the IMFs of the breast resulting in the pulled look. Likely need to rebuild the IMFs again - maybe with mesh to help with support and I agree, change the implants for higher profile to give more cleavage and upper pole fullness (or you can +/- fat graft your cleavage or upper pole area as well) Definitely worth revisiting your surgeon(s) for possible revising the IMFs and seeking out their plans, but I would recommend asking about internal bra mesh to help lock in the IMFs so the pulling is way less likely to happen.

The implants are not the major problem. The problem is that the skin of the upside down tummy tuck is attached to the breast skin and is pulling down. You need to separate the two. What I recommend is using an inframammary incision to remove the outer layer of dermis. The inner layer of dermis is still attached and is intact to the underlying fascia or ribs, pulling the tummy tuck up higher and allowing the breasts to sit independently of the tummy tuck scar.

Best Wishes,

Gary Horndeski, M.D.