Soft Tissue Scaffolds in Breast Reconstruction: Evolution from Acellular Dermal Matrices to Synthetic Polymers

Soft tissue reconstruction often requires biomaterials that provide temporary mechanical support while allowing vascular integration and tissue remodeling. In reconstructive breast surgery, these demands converge within a uniquely challenging environment characterized by large surface areas, variable perfusion, frequent exposure to radiation, and reliance on prosthetic implants. As a result, breast reconstruction has emerged as a clinically relevant model for evaluating the performance and limitations of soft tissue scaffolds. Acellular dermal matrices (ADM) were initially adopted to provide biologically derived reinforcement based on the premise of host integration and neovascularization. While ADM reshaped implant-based reconstruction, accumulating clinical experience has revealed important constraints, including variability in mechanical properties, inconsistent vascularization, susceptibility to fibrosis, and limited performance in compromised tissue beds. These limitations have driven increasing interest in synthetic polymer scaffolds engineered for predictable mechanics, controlled degradation, and scalable manufacturing. This narrative review examines the evolution from ADM to synthetic and hybrid scaffold systems in breast reconstruction. We discuss how scaffold architecture, thickness, porosity, and degradation kinetics influence angiogenesis, immune response, and mechanical load transfer during healing. Hybrid strategies that integrate selective bioactivity within synthetic frameworks are also considered, highlighting both their translational promise and practical challenges. These concepts are particularly relevant for implant-based breast reconstruction, where scaffold performance directly influences complication rates, implant stability, and long-term reconstructive outcomes.