Exosomes from preconditioned mesenchymal stem cells (MSCs) play a crucial role in tissue repair and regeneration. MSCs are widely studied for their potential in treating various diseases, with their therapeutic effects primarily mediated through paracrine mechanisms. Exosomes, as extracellular vesicles, carry bioactive molecules that regulate tissue repair and regeneration. However, exosomes have limitations such as limited secretion, poor targeting, and single functionality. MSC preconditioning can enhance exosome production, stability, and therapeutic effects. Exosomes can also serve as carriers for drugs or genes, enabling precise disease treatments. MSC preconditioning methods include hypoxia, genetic modification, proinflammatory cytokines, drugs, and chemical agents. Hypoxia improves MSC survival and exosome function. Genetic modification enhances MSC survival, proliferation, and immunomodulation. Proinflammatory cytokines improve exosome bioactivity. Drugs like atorvastatin and Kartogenin enhance exosome therapeutic effects. 3D cell culture models improve exosome production and function. Exosomes from preconditioned MSCs have shown promise in various tissue repair applications, including bone, cartilage, oral and maxillofacial, skin, neural, heart, liver, and other tissues. They promote angiogenesis, tissue regeneration, and reduce inflammation. Exosomes derived from MSCs preconditioned with hypoxia, genetic modification, or other methods have enhanced therapeutic effects in animal models. Exosomes from MSCs have potential in treating cardiovascular diseases, liver injury, and graft rejection. They can be used as cell-free therapies, offering advantages over direct cell transplantation. However, challenges remain in understanding the precise mechanisms of exosome action and improving their targeting and delivery. Future research should focus on optimizing exosome production, delivery systems, and combining multiple preconditioning methods to enhance therapeutic efficacy. 3D culture and surface engineering strategies are promising approaches for improving exosome-based therapies. Exosomes show great potential in regenerative medicine as novel biomaterials or gene/drug carriers.Exosomes from preconditioned mesenchymal stem cells (MSCs) play a crucial role in tissue repair and regeneration. MSCs are widely studied for their potential in treating various diseases, with their therapeutic effects primarily mediated through paracrine mechanisms. Exosomes, as extracellular vesicles, carry bioactive molecules that regulate tissue repair and regeneration. However, exosomes have limitations such as limited secretion, poor targeting, and single functionality. MSC preconditioning can enhance exosome production, stability, and therapeutic effects. Exosomes can also serve as carriers for drugs or genes, enabling precise disease treatments. MSC preconditioning methods include hypoxia, genetic modification, proinflammatory cytokines, drugs, and chemical agents. Hypoxia improves MSC survival and exosome function. Genetic modification enhances MSC survival, proliferation, and immunomodulation. Proinflammatory cytokines improve exosome bioactivity. Drugs like atorvastatin and Kartogenin enhance exosome therapeutic effects. 3D cell culture models improve exosome production and function. Exosomes from preconditioned MSCs have shown promise in various tissue repair applications, including bone, cartilage, oral and maxillofacial, skin, neural, heart, liver, and other tissues. They promote angiogenesis, tissue regeneration, and reduce inflammation. Exosomes derived from MSCs preconditioned with hypoxia, genetic modification, or other methods have enhanced therapeutic effects in animal models. Exosomes from MSCs have potential in treating cardiovascular diseases, liver injury, and graft rejection. They can be used as cell-free therapies, offering advantages over direct cell transplantation. However, challenges remain in understanding the precise mechanisms of exosome action and improving their targeting and delivery. Future research should focus on optimizing exosome production, delivery systems, and combining multiple preconditioning methods to enhance therapeutic efficacy. 3D culture and surface engineering strategies are promising approaches for improving exosome-based therapies. Exosomes show great potential in regenerative medicine as novel biomaterials or gene/drug carriers.