Background: The optimal prevention and treatment of pain associated of iliac crest bone graft donor sites for the treatment of cleft alveolus defects has not been well characterized. The aim of this study is to assess the efficacy of minimal access bone graft techniques with or without regional anesthesia in iliac crest bone harvest and compare to outcomes to traditional open harvest techniques. Methods: A retrospective review of 46 patients undergoing iliac crest bone harvest using traditional open iliac crest bone graft (ICBG) alone (Group 1, n = 20), minimal access ICBG (Group 2, n = 20), or minimal access ICBG with paravertebral anesthetic block (Group 3, n = 5) was performed. Post operative pain scores, narcotic consumption, and hospital stay were analyzed. Results: The average time to first narcotic was 247 minutes in Group 1, 193 in Group 2, and 1162 minutes in Group 3 ( P < .0002). Total narcotic use was 0.117 mg/kg in Group 1, 0.131 mg/kg in Group 2, and 0.072 mg/kg in Group 3. The average pain score (VAS) was 2.96 in Group 1, 1.83 in Group 2, and 1.08 in Group 3 ( P < .01). The average length of stay was 1.45 for Group 1, 1.36 for Group 2, and 1.0 for Group 3. Bone graft extrusion occurred in 6 patients (27.3%) in Group 1 and none in Group 2 or 3. There were no wound infections, bleeding requiring reoperation, or mortalities. Conclusion: The addition of regional anesthesia to minimal access alveolar bone graft harvest significantly reduces time to first narcotic use. Although not significant, a strong trend was found with regional anesthesia to lower the pain score (VAS) and total narcotic use. Regional anesthesia did not significantly reduce the length of hospital stay compared to either group. Minimal access techniques with supplemental regional anesthesia significantly lowered the pain score and time to first narcotic and trended to decreased length of hospitalization and total narcotic use compared to traditional open techniques.