Interface before bulk: Mechanism-informed strategy for preventing postoperative adhesion based on polymer implants

Postoperative adhesions (POAs) are a pervasive and serious complication following surgery, representing a major clinical challenge across multiple specialties. Drawing upon a comprehensive review of recent literature, this article systematically re-examines the prevention mechanisms of POAs with a specific focus on anti-adhesion implants (AAIs). Through analyzing diverse biological, chemical, and physical studies at the tissue interface, we propose a conceptual framework that emphasizes the dominant role of the AAI-tissue interface in the initiation and progression of adhesions. Unlike conventional bulk-focused designs, this interface-driven approach targets early adhesion events for enhanced efficacy. In this framework, the interface properties of AAIs, such as anti-fouling, anti-inflammatory, and anti-fibrotic effects, are recognized as the primary determinants of anti-adhesion efficacy, while bulk properties, including mechanical strength, degradation kinetics, and compliance, serve as essential supportive factors to maintain and reinforce interface functionality. Additionally, we highlight recent advancements in polymer-based AAIs, including mechanistically informed surface modifications and bulk material optimizations, which collectively aim to enhance both interface performance and structural durability. This structured discussion not only synthesizes current findings but also establishes a guiding principle: that effective adhesion prevention should prioritize interface-driven design strategies, complemented by tailored bulk material engineering. STATEMENT OF SIGNIFICANCE: We present an "interface-before-bulk" design strategy that rethinks how polymer-based anti-adhesion implants (AAIs) are engineered to prevent post-surgery tissue adhesions, a pervasive surgical complication. Unlike conventional approaches that focus on an implant's bulk properties or passive barrier function, this approach emphasizes the implant-tissue interface as the critical determinant of success. By framing adhesion formation as a stepwise interface-driven process, we pinpoint key stages for intervention and highlight surface modifications (anti-fouling, anti-inflammatory, anti-fibrotic) that proactively disrupt adhesion pathways. This interface-first perspective, supported by appropriate bulk material properties, offers a new framework for designing AAIs with improved clinical efficacy, guiding a shift from passive barrier designs to proactive interface engineering.