Taking Bone Grafts from the Anterior and
Posterior Ilium–-Tools and Techniques:
II. A 6800-Case Experience in Maxillofacial
and Craniofacial Surgery
P. Tessier, M.D., H. Kawamoto, M.D., D. Matthews, M.D., J. Posnick, M.D., Y. Raulo, M.D.,
J. F. Tulasne, M.D., and S. A. Wolfe, M.D.
Miami, Fla.
HISTORY
The ilium was used after the tibia as a donor
site for bone grafts by the orthopedist for fus-
ing the lumbar spine and then for the consol-
idation of pseudoarthrosis of the limbs in the
late 1800s, and it was not long before the same
donor sites were used for mandibular recon-
struction.1 In 1915 Klapp and Schroeder2 and
in the following year Lindermann3 reported
that they used the ilium to reconstruct a man-
dibular defect. Lindemann reported that he
had performed 115 cases of successful mandib-
ular reconstruction using tibial grafts but then
stated that he preferred the ilium, which he
had used in an additional 160 cases.4 Maxillo-
facial surgeons extensively used the anterior
iliac crest for the repair of fractures during
World War II.5 For 50 years, the ilium has been
the general handmaiden for all facial and cra-
nial repairs until the advent of calvarial grafts.6
There is still no limit as to its use in cranial
vault, subfrontal base, orbit, nasal, malar, max-
illary, or mandibular defects.7,8 Preferences for
a given donor site exist, but there is no limita-
tion yet for the ilium.
I. Peculiar Qualities of Iliac Grafts
• They can consolidate bridging bony de-
fects.
• They allow easy reoperation for addition of
further bone or remodeling.
DOI: 10.1097/01.prs.0000173951.78715.d7
25S
• Dental implants may be placed in the
graft.
• Iliac bone grafts, in essence, have no weak
points.
II. Purported Inconveniences of Using Iliac
Grafts
• Morbidity that is associated with taking the
graft. Other than pain, the morbidity is
practically nil (see section VIII: Compli-
cations).
• It is difficult to take a large amount of graft
material. This is not a valid argument
when the proper retractors are used.
• Time spent in the operating room is increased.
When the proper technique and appro-
priate instruments are used, it takes 15 to
30 minutes to harvest the graft. The
added expense is offset by the cost sav-
ings of not having to use an alloplastic
implant.
• The iliac crest is deformed. This is not true
when the proper technique is used by
splitting the crest into two thin halves
and then wiring them together.
• It can be painful and disabling. This is vari-
able and of 2 to 5 days’ duration, de-
pending on the extent of the procedure.
• Hospitalization is increased. It takes 2 or 3
days to recover, in general, less than the
time required for recovery from the fa-
cial repairs.
26S PLASTIC AND RECONSTRUCTIVE SURGERY,
FIG. 1. (Left) The inner aspect of the ilium showing the crest and inner donor sites. (Right) The outer showing the splitting
of the crest and the anterior and posterior donor sites.
III. Principle of the Technique
• Preserve the shape of the iliac crest by
splitting the crest properly.
• Avoid postoperative pain by securely
wiring the two halves of the split crest
back together.
• Promote complete regeneration of the
iliac wing so that it may be reharvested 2
years later.
FIG. 2. Instruments for harvesting iliac grafts: A, B, and C,
(Left) The inner aspect of the ilium showing the crest and
inner donor sites. (Right) The outer showing the splitting of
the crest and the anterior and posterior donor sites.
October Supplement 2005
IV. What Not to Do
• Do not cut or stretch the lateral femoral
cutaneous nerve by unnecessary supe-
rior dissection.
• Do not remove the iliac crest itself.
• Do not lacerate the gluteal muscles.
V. What Must Be Preserved
• Always preserve the crest with the inser-
tions of the abdominal and gluteal mus-
cles on two halves.
• Preserve either the outer or the inner
cortical plate or both of the iliac wings,
depending on the amount of material
needed.
FIG. 3. The skin incision is made 3 cm lateral to the crest.
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FIG. 4. (Left) Splitting of the crest and detaching the abdominal muscles medially and gluteal muscles laterally.
(Right) Extended subperiosteal elevation of the iliac and gluteal muscles.

FIG. 5. (Left) Splitting of the crest medially and reflection with the abdominal muscles attached. (Right) The
medial and lateral aspects of the ilium exposed, with the split crest segments beneath the retractors.

VI. What Can Be Extracted (Fig. 1) VII. How to Proceed

• A massive subcrest corticocancellous
graft as long as 11 cm.
• Up to 6 ⫻ 10 cm of the corticocancel-
lous inner plate.
• Approximately 5 ⫻ 8 cm of the cortico-
cancellous outer plate.
• A large amount of cancellous bone
down to the cotyloid ridge above the
glenoid fossa, particularly anteriorly.
A. Preparation
• The patient can be positioned either
supine or with the hip raised on a
bath towel.
• The placement of the surgeon, assis-
tant, scrub nurse, instrument table
and instruments (Fig. 2), and the
anesthesiologist is arranged for the
most efficient movement of the sur-
gical team.
28S PLASTIC AND RECONSTRUCTIVE SURGERY, October Supplement 2005

FIG. 6. (Left) Taking a long upper graft. (Center) Taking a large corticocancellous graft medially. (Right) Taking a number
of “tailored-in situ” corticocancellous grafts laterally.

FIG. 7. Wiring of the two halves of the crest.

• Landmarks are drawn after palpa- C. Surgical Maneuvers (Figs. 4 through 9)

tion. They are as follows: (1) the
anterior iliac spine and (2) the tu-
bercle of the iliac crest. The incision
lies approximately 5 cm below the
crest and lateral femoral cutaneous
nerve (Fig. 3).
B. Precautions
• From the beginning to the end, one
must watch for laceration of the
outer periosteum and the gluteal
muscles and bleeding from the cen-
tral artery of the iliac bone when
dissection is deep.
• The assistant pulls the skin medially to
position the line of incision over the
crest.
• The incision (6 to 10 cm) is made
through the superficial fascia. No subcu-
taneous dissection is required. Three or
four hemostats are used to clamp the
bleeding vessels and they are used to
help evert the wound edges.
• Two serrated Farabeuf retractors are
applied medially to retain the abdom-
inal soft tissues from encroaching into
the wound.
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FIG. 8. (Left) First twisting of the stainless steel wires (0.050 mm). (Center) Final twisting of the wires. (Right) Amount of
bone harvested from one iliac side.
FIG. 9. Osteomicrotome for grinding the remnants of the grafts.
• The index finger palpates the crest,
anterior spine, and tuberosity and
identifies the donor zone.
• An incision is made through the apo-
neurosis and the periosteum at the top
of the crest; there is no need to elevate
the periosteum on the crest.
• The osteotomes have a mushroom
head and firm handles, and the sharp
thin blades are 10, 15, and 20 mm in
width. They are used to split the crest
in an oblique manner.
• The splitting of the crest is the key maneu-
ver9 because it preserves the contour of
the iliac crest, minimizes postoperative
pain, and promotes regeneration of
the iliac wing without noticeable re-
duction in the volume of the graft re-
moved. The split in the crest is ex-
tended approximately 10 mm
anteriorly and posteriorly to the antic-
ipated extraction zone so that, when
the two halves are wired together, the
crest will be restored and resting on
stable bone. Thus, the split of the crest
is extended just behind the anterior
II 29S
spine to which it can be firmly secured
at the time of closure.
• The medial leaf of the split crest is
formed first. Starting at the height of
the iliac crest, a sharp osteotome 15 or
20 mm in width is directed in an in-
feromedial direction. The hammering
is done gently to prevent damage to
the medial periosteum. The bone is
cut all along the desired length before
prying the medial leaf medially. The
leaf is moved as a single piece with the
attachments of the abdominal mus-
cles. The medial periosteum and the
origin of the iliacus are easily elevated.
Sponges and specially designed retrac-
tors maintain the medial displacement
of the leaf.
• The lateral part of the crest is then
split in the same fashion, but the split-
ting must follow the convexity of the
crest so as to save as much of the bone
as possible. The osteotome must not
be driven into the gluteal muscle. The
lateral wing is reflected in one piece.
The gluteus maximus has strong at
30S PLASTIC AND RECONSTRUCTIVE SURGERY,
FIG. 10. An automobile accident resulted in large
fronto-orbital defects, including the entire orbital roof.
Enucleation. Reconstruction was done with iliac bone
grafts for the orbital roof, medial orbital wall, supraorbital
ridge, and frontal bone. Medial and lateral canthopexies.
Ocular prosthesis.
FIG. 11. Procedure performed on patient shown in Figure 10.
FIG. 12. Preoperative and postoperative radiographs of patient shown in Figure 10.
October Supplement 2005
tachments to the ilium. A wide,
curved, sharp elevator must be used to
dissect it off the lateral surface of the
ilium. Again, sponges and special re-
tractors are used to maintain the lat-
eral leaf in its reflect position.
• The bone grafts are extracted accord-
ing to the quantity needed with
straight or curved thin osteotomes of
10-, 15-, or 20-mm widths. They can be
harvested as monocortical or bicorti-
cal pieces, or they can be “precut” in
situ to meet the dimensional demands
of the recipient site.
• From the “subcrest” region, it is possi-
ble to harvest a graft up to 10 cm in
length to be used in mandibular and
supraorbital ridge reconstructions.
• The inner table is slightly concave and
adapts perfectly for all orbital defects.
• Pieces 6 to 10 cm have been taken for
cranioplasties.
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FIG. 13. Median facial dysrhaphia (no. 0-14 cleft). Major hypertelorism; hypoplasia of the nasal framework. Correction of the
hypertelorism was by the usual intracranial procedure. Massive iliac graft of the nasal structures.

• The lateral anterior portion of the
wing fits well for orbital and zygo-
matic defects.
• Cancellous bone grafts are easily
taken with gouges and curettes
from almost everywhere.
• It is possible to extend the donor site
in a deep anterior direction. The iliac
bone thickens considerably as one ap-
proaches the cotyloid ridge or the in-
ferior attachment of the iliacus muscle
above the glenoid fossa. Reaching this
area is only a matter of using long
retractors and elevators for taking ad-
ditional corticocancellous grafts.
Bleeding is controlled by applying
32S PLASTIC AND RECONSTRUCTIVE SURGERY, October Supplement 2005

FIG. 14. Otomandibular dysplasia; agenesis of the right ramus. Construction of the ramus and angle with an iliac bone graft
along with maxillary and mandibular osteotomies and a genioplasty.

bone wax or by electrocoagulation of tral iliac artery, which is easily done

the gluteus maximus. Rapid bleeding with bone wax. Any surplus wax must
indicates the need to control the cen- be removed.
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FIG. 15. Percutaneous harvest of iliac bone in a 5-year-old with an alveolar cleft. The skin incision is several centimeters by the entry
point into the ilium, marked with a circle. The shorter of the two metal rods goes in to the follow cutter to prevent collapse during
hammering; the larger rod is then used to express the bone core. The bone cores harvested at this age contain some cartilage, which is
probably genetically programmed to become bone but which nevertheless is place high along the pyriform rim and not in areas where there
will be tooth eruption.

FIG. 16. (Left) Instruments for percutaneous harvest. (Right) Cores of cancellous bone and cartilage; more could easily be
harvested.

FIG. 17. Alveolar defect before (left) and after (right) grafting with percutaneously harvested iliac bone.

• The closure: • Four 26-gauge (0.50-mm) wires are

• A large piece of Gelfoam is placed passed with awls with different cur-
into the periosteal pocket of the do- vatures and twisted individually to
nor site. approximate themedial and lateral
34S PLASTIC AND RECONSTRUCTIVE SURGERY, October Supplement 2005

FIG. 18. (Left) Central mandibular defect with nonunion. (Center and right) After resection back to healthy bone and
application of a mandibular reconstruction plate.

FIG. 19. (Left) With the iliac bone graft in place, performed at a subsequent operation. (Right) The iliac bone graft beneath
the reconstruction plate.

FIG. 20. (Left) Appearance of the graft 6 months later. (Right) With osseointegrated implants and attached dental prosthesis,
after 3 years.

leafs of the split crest. A final pull of
the wire is made and they are firmly
twisted down away from the wound
surface one after the other. The
ends of the leaves should rest on the
remaining anterior superior spine
to re-create a solid crest.
• In case of instability of the reformed
crest, a fifth wire is fixed to the an-
terior iliac spine.
• The aponeurosis of the muscles,
subcutaneous tissue, and skin are
closed in layers.
D. Variation for Taking Grafts for the Pos-
terior Iliac Tuberosity.
• Taking grafts in the prone position
from the posterior tuberosity is a
classic orthopedic procedure when
lumbar spine fusion is performed.
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FIG. 21. Preoperative views of patient with posttraumatic
saddle nose deformity with depressed anterior wall of frontal
sinus.
FIG. 22. Same patient as shown in Figure 21, 10 years after
massive iliac bone graft to nose and frontal area and correc-
tion of right enophthalmos.
• The amount of cancellous bone that
is available for facial reconstructions
is considerable. However, changing
the patient’s position from prone to
supine is inconvenient. This is why
we have established the supine ap-
proach for harvesting posterior tu-
berosity grafts. Its indication is when
the anterior iliac source previously
has been exhausted. It is not possi-
ble to use this in obese patients.
• A headlight is recommended.
• The posterior pelvis is firmly raised
on a sandbag or tightly rolled towels.
• The two legs are turned to the con-
tralateral site.
• The skin incision is made on the
medial third of the crest that is ex-
posed as previously described.
TOOLS AND TECHNIQUES: PART II 35S
FIG. 23. (Left) Preoperative and (right) 10-year postoper-
ative radiographs of the nose.
• A 10-cm subperiosteal dissection of
the crest is made.
• An osteotome is used to elevate the
crest; true splitting of the medial
third is difficult and often incom-
plete.
VIII. Complications (Overall Rate, 0.6 Percent)
A. Intraoperative
• Fracture of the leaves of the split
crest can occur. A fracture of the
opposite leaf must therefore be
avoided.
Bleeding from the bone can always
be controlled with Surgicel, Gel-
foam, or bone wax.
• Bleeding from the gluteal arteries
is controlled by the pressure of the
retractors transmitted to the under-
lying sponge and then by electroco-
agulation. It is always the conse-
quence of penetration of the
muscle by the osteotome or perios-
teal elevator or inappropriate re-
traction.
• Bleeding from the iliac central ar-
tery (five cases) can be easily
stopped by the use of bone wax.
B. Postoperative
• Hematomas (six cases) had to be
evacuated and irrigated and bleed-
ing points controlled. The crest is
reconstituted as mentioned before.
• Infection occurred in one case in
which a sponge was retained in the
wound.
• Retained surgical sponges re-
quired subsequent removal in two
other instances.
36S PLASTIC AND RECONSTRUCTIVE SURGERY, October Supplement 2005

FIG. 24. Preoperative views of patient who had an accident at work, showing the fronto-orbital defect and enophthalmos. Reconstruction
was done with iliac bone grafts for the orbital floor, medial wall, roof, and frontal defect, and medial and lateral canthopexies.

FIG. 25. Preoperative and postoperative radiographs.

TABLE I
Instruments Used to Take Iliac Grafts

Group A: Ordinary Bone Instruments Group B: Specific Iliac Bone Instruments

One strong skin forceps One long Lambotte periosteal elevator
Eight hemostats to evert the skin edges One short-handle heavy mallet
Two Farabeuf type serrated retractors Four straight, thin osteotomes (10, 15, and 20 mm)
Two wide Obwegeser periosteal elevators Four curved thin osteotomes (10, 15, and 20 mm)
Two medium-size bone holders Four Tessier iliac retractors
One double-action angled short blade bone cutter Two gouges, two deep or hollow curettes
One single-action angled rongeur One serrated bone cutter
Six strong wire twisters One Tessier bone bender
Two wire cutters Three curved awls for wiring the crest leaves
Rolls of 24-, 26-, and 28-gauge steel wire Six strong wire twisters
One The Osteo-Microtome (TOM)
Cartilage bender for compacting bone chips
For posterior approach
• Two long Z-shaped serrated skin retractors
• Two Tessier long thoracic retractors

• A skin incision being placed to • Pain caused by pressure or palpa-

cephalad or needless cephalic sub- tion on the crest is usually caused
cutaneous dissection caused pares- by the tip of a twisted wire that has
thesia in the inguinal or crural re- been inadequately turned in. In
gion (10 cases). eight instances, the wire broke
Vol. 116, No. 5 October Supplement 2005 / TOOLS AND TECHNIQUES: PART
spontaneously and had to be re-
moved.
• A hernia occurred once when a
second harvest was attempted and
there was a laceration of the ab-
dominal muscles because of im-
proper retraction.
Elsewhere in the literature, a number of
complications have been cited that were
not encountered in our series, including
adynamic ileus,10 and postoperative frac-
ture of the ilium11 and some of which
were.12
IX. The Tools (Figs. 2, 9, and 10)
The instruments used for taking iliac
grafts can be placed into two categories
• Group A: ordinary bone instruments.
• Group B: specific instruments that fa-
cilitate the fast harvest of iliac bone
grafts (Table I).
S. Anthony Wolfe, M.D.
Miami Children’s Hospital
3100 SW 62nd Avenue, Suite 120
Miami, Fla. 33155
awolfemd@bellsouth.net
II 37S
REFERENCES
1. Ivy, R. Bone grafting for restoration of defects of the
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Berlin: Hermann Meusser, 1917.
3. Lindermann, A. Bruhn’s Ergebnisse aus dem Düsseldorfer
Lazareff. Wiesbaden: Kieferschussverletzungen, 1916.
P. 243.
4. Lindemann, A. Quoted by Dolomore, W. H. Br. Dent. J.
38: 16, 1917.
5. Mowlem, R. Cancellous chips bone grafts: Report on 72
cases. Lancet 2: 746, 1944.
6. Tessier, P. Autogenous bone grafts taken from the cal-
varium for facial and cranial applications. Clin. Plast.
Surg. 9: 531, 1982.
7. Sheehan, J. E. Use of iliac bone in the facial and cranial
repair. Am. J. Surg. 52: 55, 1941.
8. Dingman, R. O. The use of iliac bone on the repair of
facial and cranial defects. Plast. Reconstr. Surg. 3: 24,
1950.
9. Wolfe, S. A., and Kawamoto, H. K. Taking the iliac bone
grafts. Bone Joint Surg. (Am.) 60: 411, 1978.
10. James, J. D., Geist, E. T., and Gross, B. D. Adynamic
ileus as a complication of iliac bone removal. J. Oral
Surg. 39: 289, 1981.
11. Kalk, W., Raghoebar, G., Jansma, J., and Boering,
G. Morbidity from iliac crest bone harvesting. J. Oral
Maxillofac. Surg. 54: 1424, 1996.
12. Weikel, A., and Habal, M. Meralgia paresthetica: A com-
plication of iliac bone procurement. Plast. Reconstr.
Surg. 4: 572, 1977.