This review article explores the therapeutic potential of exosomes derived from preconditioned mesenchymal stem cells (MSCs) in tissue repair and regeneration. MSCs, known for their ability to differentiate into various cell types and their immunomodulatory properties, have gained significant attention in regenerative medicine. Exosomes, small extracellular vesicles secreted by MSCs, play a crucial role in paracrine mechanisms by regulating surrounding cells and tissues. However, exosomes have limitations such as limited secretion and poor targeting. Preconditioning MSCs, such as through hypoxia, genetic modification, proinflammatory cytokines, drugs, and chemical agents, enhances exosome production and function, improving therapeutic outcomes. The article discusses the effects of preconditioning on exosomes in various tissues, including bone, cartilage, oral and maxillofacial regions, skin, neural tissue, heart, and liver. For example, hypoxic preconditioning of MSCs increases the expression of angiogenic factors, enhancing bone and wound healing. Genetic modifications, such as overexpression of miRNAs, can enhance the therapeutic efficacy of exosomes in cartilage and skin regeneration. Proinflammatory cytokines and drugs like atorvastatin and hydrogen sulfide improve exosome function in tissue repair and reduce inflammation. The review also highlights the use of exosomes in treating specific diseases, such as periodontitis, spinal cord injury, and cardiovascular diseases. For instance, exosomes from MSCs preconditioned with hydrogen sulfide show neuroprotective effects in traumatic brain injury models. In spinal cord injury, exosomes from MSCs preconditioned with hydrogen sulfide enhance functional recovery by reducing neuroinflammation and promoting axonal regeneration. Finally, the article concludes by discussing the challenges and future prospects in the field. It emphasizes the need for further research to understand the precise mechanisms of exosome actions, improve exosome production and delivery systems, and address the heterogeneity of MSCs. Despite these challenges, the potential of exosomes derived from preconditioned MSCs in regenerative medicine is promising, offering new avenues for cell-free therapies.This review article explores the therapeutic potential of exosomes derived from preconditioned mesenchymal stem cells (MSCs) in tissue repair and regeneration. MSCs, known for their ability to differentiate into various cell types and their immunomodulatory properties, have gained significant attention in regenerative medicine. Exosomes, small extracellular vesicles secreted by MSCs, play a crucial role in paracrine mechanisms by regulating surrounding cells and tissues. However, exosomes have limitations such as limited secretion and poor targeting. Preconditioning MSCs, such as through hypoxia, genetic modification, proinflammatory cytokines, drugs, and chemical agents, enhances exosome production and function, improving therapeutic outcomes. The article discusses the effects of preconditioning on exosomes in various tissues, including bone, cartilage, oral and maxillofacial regions, skin, neural tissue, heart, and liver. For example, hypoxic preconditioning of MSCs increases the expression of angiogenic factors, enhancing bone and wound healing. Genetic modifications, such as overexpression of miRNAs, can enhance the therapeutic efficacy of exosomes in cartilage and skin regeneration. Proinflammatory cytokines and drugs like atorvastatin and hydrogen sulfide improve exosome function in tissue repair and reduce inflammation. The review also highlights the use of exosomes in treating specific diseases, such as periodontitis, spinal cord injury, and cardiovascular diseases. For instance, exosomes from MSCs preconditioned with hydrogen sulfide show neuroprotective effects in traumatic brain injury models. In spinal cord injury, exosomes from MSCs preconditioned with hydrogen sulfide enhance functional recovery by reducing neuroinflammation and promoting axonal regeneration. Finally, the article concludes by discussing the challenges and future prospects in the field. It emphasizes the need for further research to understand the precise mechanisms of exosome actions, improve exosome production and delivery systems, and address the heterogeneity of MSCs. Despite these challenges, the potential of exosomes derived from preconditioned MSCs in regenerative medicine is promising, offering new avenues for cell-free therapies.