What Is a Buffalo Hump? Causes and Treatment

A buffalo hump is a visible pad of fat that builds up at the base of the neck, between the shoulder blades, in the area doctors call the dorsocervical region. It can range from a subtle fullness you notice only when tilting your head forward to a prominent mound that changes the profile of your neck and upper back. The deposit itself is not a disease but a physical sign that something has shifted in how your body stores fat, and the list of possible drivers runs from hormonal disorders and medications to straightforward obesity. Because the causes vary so widely, figuring out why the hump appeared matters at least as much as deciding how to treat it.

Why Fat Builds Up in That Specific Spot

The back of the neck is not just any patch of skin and fat. Anatomical studies show that the fat tissue there is woven through with thick, vertically oriented fibrous walls that anchor it to the deep cervical fascia and the nuchal ligament, the tough band running down the back of your neck. These fibrous partitions create small compartments that hold fat in place and limit how easily it can shift around. In conditions that cause abnormal fat growth, the fibrous content can increase further, blurring the boundary between the pathological fat pad and the normal fat surrounding it.¹ That structural anchoring is one reason the hump can be so stubborn: the fat is not just sitting on top of the muscle, it is tethered into the deeper tissues.

The hormonal explanation for why excess cortisol or other metabolic disruptions favor this location specifically remains an active area of research, but part of the answer lies in the biology of visceral and upper-trunk fat. Fat cells in the trunk and around internal organs carry more cortisol receptors than fat cells in the arms or legs. When cortisol is chronically elevated, those receptor-rich depots absorb more lipid. A study of women treated for Cushing’s syndrome confirmed that normalizing cortisol levels led to a redistribution of fat away from visceral depots and back toward the limbs, reinforcing the idea that cortisol directly drives fat toward the trunk.²

Cushing’s Syndrome and Corticosteroid Medications

The classic medical association with a buffalo hump is Cushing’s syndrome, a condition in which the body is exposed to abnormally high levels of cortisol for a prolonged period. Cushing’s can arise from a pituitary tumor that overproduces the hormone ACTH, from an adrenal gland tumor, or from taking prescription corticosteroids such as prednisone. In all of these scenarios, the excess cortisol reshuffles fat storage, pulling it away from the arms and legs and packing it into the abdomen, the face (producing the round “moon face”), and the dorsocervical region.

Prescription corticosteroids are by far the most common trigger. Millions of people take drugs like prednisone, dexamethasone, or hydrocortisone for conditions ranging from asthma and rheumatoid arthritis to organ transplant management. At high enough doses or over a long enough period, these medications mimic what happens in endogenous Cushing’s. Case reports document patients developing a buffalo hump alongside moon face and other fat redistribution after sustained high-dose prednisone.³ The good news is that when the steroid dose is tapered or discontinued, the fat redistribution often at least partially reverses, though this can take months.

One important distinction: not everyone on corticosteroids develops a hump. The dose, duration, and individual susceptibility all matter. Low-dose inhaled steroids for asthma, for example, are far less likely to cause systemic fat redistribution than months of oral prednisone at high doses. If you notice a growing fullness at the back of your neck while taking any corticosteroid, it is worth flagging with your doctor rather than assuming it is harmless weight gain.

HIV Treatment and Lipodystrophy

People living with HIV who take antiretroviral therapy face a distinct but related risk. A condition called HIV-associated lipodystrophy can cause fat to waste away from the face, arms, and legs while simultaneously accumulating in the abdomen and the dorsocervical area. The combination of skeletal-looking limbs and a buffalo hump is visually striking and, for many patients, deeply distressing.

The mechanisms behind this fat redistribution are complex and not fully understood. They involve a mix of direct effects from HIV proteins on fat cells, side effects from antiretroviral drugs, genetic predisposition, increased inflammation, and changes in the immune system after infection.⁴ Earlier generations of antiretroviral drugs, particularly certain protease inhibitors and nucleoside reverse transcriptase inhibitors, were strongly linked to lipodystrophy through mechanisms involving damage to the energy-producing machinery inside cells and disruption of insulin signaling.⁵ Newer drug regimens have improved the picture, but cases still occur. One case report documented a patient developing a buffalo hump on a regimen including raltegravir and unboosted atazanavir, even in the absence of other metabolic risk factors, suggesting that some degree of pharmacological causation persists with modern drugs.⁶

For people with HIV, the fat changes are far from cosmetic. Research has found that lipodystrophy can have a profoundly negative social and psychological impact, leaving patients feeling disfigured and stigmatized, and it can even reduce willingness to stick with life-saving antiretroviral therapy.⁷ That makes treatment of the hump a clinical priority, not a vanity concern. Management strategies include switching to less toxic antiretroviral drugs, adding medications to address insulin resistance or abnormal lipids, and in some cases growth hormone analogs.⁸

Obesity, Metabolic Syndrome, and Idiopathic Cases

Not every buffalo hump traces back to Cushing’s or antiretroviral drugs. A growing body of evidence links dorsocervical fat accumulation to plain metabolic disease. A study of patients with non-HIV-associated buffalo humps found that the majority were obese, with a mean BMI over 30, and that the group carried high rates of hypertension, diabetes, elevated cholesterol, and abnormal liver function.⁹ The researchers characterized the buffalo hump itself as a potential clinical marker for underlying metabolic problems, meaning that the visible fat pad may be a signal worth investigating rather than just a cosmetic issue.

Separately, research on upper-trunk fat in both HIV-positive and HIV-negative people found that higher volumes of fat in the upper trunk were independently associated with insulin resistance. Among HIV-negative controls, those with the most upper trunk fat had roughly nine times the odds of clinically significant insulin resistance compared with those who had the least.¹⁰ The fat pad at the base of your neck, in other words, is not metabolically inert. It tracks with the same insulin and lipid problems that drive cardiovascular disease.

Some patients develop a buffalo hump with no identifiable hormonal disorder, no relevant medications, and only modest weight gain. These idiopathic cases are frustrating because there is no clear lever to pull. Doctors may recommend weight loss and monitoring metabolic markers, but the structural anatomy described earlier, with its fibrous septae anchoring fat in place, means that even significant overall weight loss does not always shrink the hump proportionally.

How Doctors Figure Out the Cause

When you show up with a buffalo hump, the first question a doctor needs to answer is whether your cortisol is abnormally high. After ruling out exogenous glucocorticoid use (prescription steroids, steroid injections, even some skin creams used heavily), they typically order one or more screening tests for Cushing’s syndrome. The recommended first-line options include an overnight low-dose dexamethasone suppression test, a 24-hour urinary free cortisol collection, and a late-night salivary cortisol test.¹¹ Each test probes cortisol from a different angle, and abnormal results on two or more tests strongly support a diagnosis of Cushing’s.

If cortisol levels come back normal, the workup shifts toward metabolic screening: fasting glucose, insulin, hemoglobin A1c, a lipid panel, and liver function tests. In people living with HIV, the evaluation also includes a review of the antiretroviral regimen and possibly body composition measurements like DEXA scanning to map fat distribution. Imaging of the hump itself, usually with ultrasound, can help distinguish a simple fat pad from a lipoma or other soft-tissue mass. On ultrasound, a dorsocervical fat pad looks like tissue that matches the surrounding subcutaneous fat, sometimes with internal septae, but without displacing or compressing nearby structures the way a true mass would.¹²

Surgical Treatment and What to Expect Afterward

When the underlying cause has been addressed (or cannot be changed) and the hump persists, surgery becomes an option. The two main approaches are liposuction and excisional lipectomy, which is direct surgical removal of the fat pad. A systematic review and meta-analysis of surgical outcomes found that liposuction was the most commonly used technique. Pooled data showed a recurrence rate of about 11% and a revision rate of roughly 15% for liposuction, though a sensitivity analysis that excluded high-heterogeneity studies dropped both rates to under 2%. Excisional lipectomy and hybrid techniques that combine excision with liposuction reported a pooled recurrence rate of zero.¹³

Those numbers deserve some context. The recurrence rate with liposuction partly reflects the fibrous anatomy of the region: the thick septae that anchor the fat can make it difficult to suction out completely, and if the underlying hormonal or metabolic driver is still active, fat can reaccumulate. Ultrasound-assisted liposuction, which uses energy to break up fibrous tissue before aspiration, has been explored as a way to improve completeness of removal in particularly fibrous humps.¹

For patients with HIV-associated lipodystrophy specifically, excisional lipectomy has shown promising durability. A study following nine HIV-positive patients for a median of two years after lipectomy found that all reported satisfaction with their results and none experienced recurrence, with viral loads remaining undetectable throughout follow-up.¹⁴ That is a small study, so it should be read as encouraging rather than definitive, but it suggests that direct excision may be particularly appropriate when the fat is densely fibrous and the underlying drug regimen cannot be changed.

Buffalo Hump Versus Dowager’s Hump

One of the most common confusions is between a buffalo hump and a dowager’s hump. They occur in the same anatomical neighborhood but are entirely different problems. A buffalo hump is a fat deposit. A dowager’s hump, more formally called kyphosis, is an exaggerated forward curvature of the upper spine. It is typically caused by vertebral compression fractures related to osteoporosis, degenerative disc disease, or chronically poor posture. The visible “hump” in kyphosis comes from the curvature of the spine itself, not from fat accumulation on top of it, though in practice some people have elements of both.

A case report describing the correction of a dowager’s hump through spinal manipulation emphasized that maintaining proper posture and avoiding habitual forward head flexion are key to preventing recurrence of the postural deformity.¹⁵ That advice applies to the skeletal component. If your hump is soft and compressible when you press on it, that points toward fat. If it feels bony and rigid, the spine itself is more likely involved. Your doctor can distinguish the two quickly with a physical exam and, if needed, a lateral X-ray of the thoracic spine.

Madelung Disease and Other Rare Mimics

A less common but important condition that can mimic a buffalo hump is Madelung disease, also known as multiple symmetric lipomatosis. This rare disorder causes painless, non-encapsulated fatty deposits to grow symmetrically in the neck, upper trunk, and sometimes the limbs.¹⁶ The masses can become large enough to compress the airway or esophagus. Madelung disease is strongly associated with chronic alcohol consumption, and patients often present with features of metabolic syndrome as well.¹⁷

The key distinguishing feature is the symmetry and multifocality. A buffalo hump from Cushing’s or metabolic syndrome tends to be a single central deposit at the base of the neck. Madelung disease produces multiple fatty masses distributed around the neck and shoulders, sometimes giving the appearance of a “horse collar.” A simple lipoma, which is a benign tumor of fat cells enclosed in a capsule, is another possibility. Unlike a buffalo hump, a lipoma has clear borders, moves when you push on it, and does not change with cortisol levels or weight fluctuations. Ultrasound can usually tell these apart.

When the Hump Comes Back After Treatment

Recurrence is a real concern and one of the most frustrating aspects of buffalo hump management. The hump can return after surgical removal if the underlying metabolic or hormonal driver is still active. In HIV-associated cases, if the antiretroviral regimen continues to promote lipodystrophy, the dorsocervical fat can slowly rebuild. In corticosteroid-driven cases, restarting steroids for a flare of the original disease will often bring the hump back. Even in idiopathic cases, patients who regain weight or develop worsening metabolic syndrome may see regrowth.

The surgical data bear this out. As noted in the meta-analysis, the liposuction recurrence rate was higher than that for excisional lipectomy, and some of the heterogeneity in liposuction outcomes likely reflects differences in the underlying cause and whether it was controlled at the time of surgery.¹³ The practical takeaway is that surgery is most effective when paired with management of whatever caused the fat accumulation in the first place. Removing the hump without addressing the metabolic environment is treating the symptom but leaving the disease running.

Living With a Buffalo Hump

Beyond the medical workup and treatment options, a buffalo hump affects how people move through the world day to day. The hump can restrict neck mobility, make it uncomfortable to lie on your back, and interfere with clothing fit. For people whose hump developed because of a visible medication side effect, particularly in HIV, the psychological burden can be substantial. Research has documented that patients with lipodystrophy report feeling disfigured and socially isolated, and some reduce adherence to their antiretroviral medications specifically because of body shape changes.⁷ In the HIV context, the hump can function as a visible marker of status that patients cannot hide, compounding stigma in ways that directly threaten health outcomes.

If you are dealing with a buffalo hump, it is worth approaching it as a medical sign rather than a cosmetic annoyance. The fat deposit itself may be the least important thing about it. What it reveals about your cortisol, your insulin sensitivity, your medication side effects, or your metabolic trajectory is likely more consequential than the hump’s appearance. Getting a proper diagnostic workup can turn a frustrating physical change into an opportunity to catch and manage an underlying condition earlier than you otherwise might have.

1
PubMed Central. Ultrasound-Assisted Liposuction for Idiopathic Buffalo Hump: Anatomical Considerations and Technical Implications
2
Metabolism. Changes in body composition and adipose tissue distribution after treatment of women with Cushing’s syndrome
3
PubMed. Temporal fat pad sign during corticosteroid treatment
4
Nature Reviews Disease Primers. What Is a Buffalo Hump? Causes and Treatment
5
Journal of Antimicrobial Chemotherapy. HIV-associated lipodystrophy: a review of underlying mechanisms and therapeutic options
6
PubMed Central. Development of Buffalo Hump in the course of antiretroviral therapy including raltegravir and unboosted atazanavir: a case report and review of the literature
7
Aesthetic Surgery Journal. Lipodystrophy in the Patient with HIV: Social, Psychological, and Treatment Considerations
8
PubMed Central. Pathogenesis and treatment of human immunodeficiency virus lipodystrophy
9
PubMed Central. Non HIV-Associated Buffalo Hump as a Clinical Marker of Metabolic Disease
10
PubMed Central. Association of upper trunk and visceral adipose tissue volume with insulin resistance in control and HIV-infected subjects in the FRAM study
11
PubMed Central. Approach to the Patient: Diagnosis of Cushing Syndrome
12
European Society of Radiology. The Buffalo Hump: Sonographic differentiation of a prominent dorsocervical fat pad from lipoma
13
PubMed. Surgical Management of Dorsocervical Fibro-Lipodystrophy (Buffalo Hump): Systematic Review and Meta-Analysis
14
PubMed Central. Clinical outcome after lipectomy in the management of patients with human immunodeficiency virus-associated dorsocervical fat accumulation
15
PubMed Central. Remission of Dowager’s hump by manipulative correction of spinal alignment: a case report
16
PubMed Central. Madelung disease (multiple symmetric lipomatosis)
17
PubMed Central. Multiple symmetric lipomatosis (Madelung disease) presenting as cervical lipomatous mass in a middle-aged male with alcohol use in Nepal: A Case Report