Abstract: An attachment device used to attach appliances to tissue can incorporate microstructures. A medical device system can comprise a coupling device comprising a base layer, a coupling attached to an air side of the base layer, a microstructure attached to a skin side of the base layer and a patient interaction feature, and an appliance comprising a structure mounted to the coupling to interface with the patient interaction feature. An appliance device comprises a base layer, an appliance structure attached to an air side of the base layer, and a microstructure attached to a skin side of the base layer. An appliance attachment system comprises an appliance, a first component comprising an adhesive backing containing microstructures that are configured to attach to skin, and a second component configured to attach the appliance to the first component.