Adipose-derived stem cells (ADSCs) and their exosomes have emerged as a promising therapeutic tool in regenerative medicine, given their capacity for cellular repair, immunomodulation, and multilineage differentiation. This comprehensive review discusses the multifaceted roles of ADSCs in tissue regeneration, highlighting their mechanisms of action, including paracrine signaling and immunomodulation. The classification and biogenesis of extracellular vesicles (EVs), with a focus on exosomes, are detailed, emphasizing their molecular composition and functional significance. The therapeutic applications of ADSC-derived exosomes in neuronal regeneration, cutaneous wound healing, and orthopedic applications are explored, along with ongoing clinical trials and future prospects for clinical translation.