Despite advances in surgery, the reconstruction of segmental nerve injuries continues to pose challenges. In this review, current neurobiology regarding regeneration across a nerve defect is discussed in detail. Recent findings include the complex roles of nonneuronal cells in nerve defect regeneration, such as the role of the innate immune system in angiogenesis and how Schwann cells migrate within the defect. Clinically, the repair of nerve defects is still best served by using nerve autografts with the exception of small, noncritical sensory nerve defects, which can be repaired using autograft alternatives, such as processed or acellular nerve allografts. Given current clinical limits for when alternatives can be used, advanced solutions to repair nerve defects demonstrated in animals are highlighted. These highlights include alternatives designed with novel topology and materials, delivery of drugs specifically known to accelerate axon growth, and greater attention to the role of the immune system. K E Y W O R D S acellular nerve allograft, autograft, nerve gap, nerve guidance conduit, peripheral nerve 2 | BIOLOGY OF NERVE REGENERATION ACROSS A DEFECT Peripheral nerve is capable of robust regeneration following injury. The molecular and cellular mechanisms have primarily been studied in rodent models. Following injury, neurons and their axons and the nonneuronal cellular environment distal to the injury undergo immediate morphological and molecular changes. Within the axon, there is a rapid influx of ions, principally calcium, as well as a disruption of transport proteins signaling a disruption to homeostasis with its end-organ. This multifactorial injury response from axon damage is rapidly transported to the neuron cell Abbreviations: ANA, acellular nerve allograft; ECM, extracellular matrix; FDA, Food and Drug Administration; FK506, tacrolimus; GDNF, glial cell line-derived neurotrophic factor; GFRα1, glial cell line-derived neurotrophic factor family receptor alpha-1; MRC, Medical Research