Am I being unrealistic with the results i'm looking for? Can I achieve more upper pole fullness? (Photos)

Thank you for your question. I have been in practice for over 30 years and revisionary breast surgery is a large portion of my practice. I have taken care of 100's of cases similar to yours wanting more upper pole fullness. I have developed with a technique termed "reductive augmentation" which I published in 2017. It involves perform an internal bra/capsulorrhaphy, reaugmentation with a larger ultra high-profile implant, removal of inferior pole breast tissue, and revision of your mastopexy/lift. You should be able to have an excellent result. Best wishes to you.

You suffer an hybrid modality of bottoming out, simultaneously:
-breast implants bottoming out: the implants are likely smooth or poorly textured, or maybe you did not keep 4 strictly immobile weeks, or both; nevertheles, the implants failed to stick firmly to the ribcage and they now slide downwards due to gravity, regardless they are large or not, this phenomenon happens in any and each case of poor adhesion to tissues
-brest tissue bottoming out: your have too much own glandular tissue which is a clear cause of droopiness aka pseudoptosis or false ptosis, false because the nipples are not going down but the tissue is

Surgical plan:
-breast lift revision to reduce as much as possible the dislodged and hanging own breast tissue, the less tissue left the higher the chances of a good standing of the breast mound
-using polyurethane coated implants, of the size leading to the breast of you choosing (no limits here), they form a bio velcro with tissues and do guarantee firm fixation; other implants are not that saffe, even textured ones, I strongly recommend you find a surgeon focused in using them, few doctors are proficcient in their use because they are technically challenging

Read below and see images about breast tissue bottoming out:

If the implants don’t have sufficient tissue to support their weight against gravitational force, then they will continuously want to slide down.
Once someone has bottomed out, they are at risk for having this happen again and again, unless the implant is properly secured.This becomes more difficult if the procedure wasn’t done correctly, the first time.
Having an augmentation and needing a lift in conjunction, increases the chance of these complications.
These are also much more likely problems if large implants are selected.
Revision surgery things become more complex, and the chance of a high quality outcome generally goes down.
That doesn’t mean there isn’t room for improvement.
It simply means it’s not as easy as it would’ve been if the surgeon is working with virgin tissue.
Securing the implant to a higher position, should ideally be done by leaving sufficient amounts of pectoralis muscle to not allow the implant to slide down.
If the pectoralis muscle is completely transected, then the contraction of the muscle can push the implant downwards.
There’s no yes or no answer to your question.
There’s almost always a room for improvement, but whether you get the improvement depends on the complexity of the situation and the skill of the surgeon.
Provider selection is in the end, the most important variable apparently
Finding the right plastic surgeon to work with is also inherently difficult.
Best,
Mats Hagstrom MD