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 permitting 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. Consequently, breast reconstruction serves as a clinically relevant model for evaluating the performance and limitations of soft tissue scaffolds. Acellular dermal matrices (ADMs) were introduced to provide biologically derived reinforcement capable of host integration and neovascularization. Although ADM has transformed implant-based reconstruction, clinical experience has revealed important limitations, including variability in mechanical properties, inconsistent vascularization, susceptibility to fibrosis, and suboptimal performance in compromised tissue beds. These challenges have driven increasing interest in synthetic polymer scaffolds engineered for reproducible 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 incorporate selective bioactivity within synthetic frameworks are also explored, highlighting their translational promise and current limitations. These principles are particularly relevant in implant-based breast reconstruction, where scaffold performance directly influences complication rates, implant stability, and long-term outcomes. Collectively, breast reconstruction serves as a rigorous translational model demonstrating that optimal soft tissue scaffolds must balance vascular permissiveness, mechanical reliability, and predictable resorption to optimize reconstructive success and guide future biomaterial innovation.