Extracellular vesicles (EVs) play a critical role in various physiological and pathological processes. EVs have gained recognition in regenerative medicine due to their biocompatibility and low immunogenicity. However, the practical application of EVs faces challenges such as limited targeting ability, low yield, and inadequate therapeutic effects. To overcome these limitations, engineered EVs have emerged. This review aims to comprehensively analyze the engineering methods utilized for modifying donor cells and EVs, with a focus on comparing the therapeutic potential between engineered and natural EVs. Additionally, it aims to investigate the specific cell effects that play a crucial role in promoting repair and regeneration, while also exploring the underlying mechanisms involved in the field of regenerative medicine.