Recent advancements in surface engineering have redefined the design of biomaterial implants, offering new strategies for controlling the immune response and improving device performance. In this review, we examine an array of approaches for modulating the host's foreign body response through surface modifications, including topographical alterations, mechanical tuning, and chemical modification. We detail how these strategies influence cell adhesion, protein adsorption, and macrophage behavior, ultimately reducing the level of fibrosis. Special focus is placed in this review on two principal strategies: zwitterionic coatings that reduce protein fouling and triazole-based modifications that modulate immune cell activity. We also examine recent efforts to integrate these paradigms and highlight how engineered surfaces can alter lipid depositions, revealing new insights into the foreign body response. Ultimately, these insights pave the way for next-generation biomaterial implants while accentuating the ongoing need to unravel the physiochemical relationship between engineered surfaces and immune dynamics in order to achieve clinical success.