Justin Yovino, M.D.
Board Certified Plastic & Reconstructive Surgeon
Beverly Hills, California
The presence of a dorsocervical fat pad in the general population is significantly more common than currently appreciated by the medical community. Due to similarities with the American bison, a dorsocervical fat pad is referred to as a ‘buffalo hump.’ It is subcutaneous adipose tissue in a centripetal distribution. Drug-induced and disease-related buffalo humps are well-documented but are not the focus of the present discussion. Furthermore, the etiology of all other humps is often idiopathic and likely a normal variant of body fat distribution.
Accumulation of fat in this area is often considered to be disfiguring for the affected individual, and to a lesser extent, can be functionally impairing. Prior to the internet and social media explosion, most patients suffered in silence with this unsightly appearance. Requests to remove the buffalo hump have become increasingly common given the realization that successful treatment and intervention exists.
While there are other causes of dorsal neck abnormalities, including cervical kyphosis and tumors, it is generally believed that hypertrophied fat—-, not bone or muscle—is the cause of the so-called buffalo hump. It consists of skin, varying degrees of dense connective tissue, and variable amounts of adiposity. Consider that in the anatomy of buffalos, the hump is comprised of muscle and bone 1; The only similarity with its expression in humans is the location between the shoulders and over the lower neck and upper back.
The fat is uniformly located in the constricted subcutaneous space, deep to the skin, and superficial to the trapezius muscle origin. The fat pad is consistently midline and centered over the C7 or T1 spinous processes. It extends superiorly to inferiorly from approximately C4 to T4 and spans horizontally between the angle of the ribs or the medial borders of the scapulae. It is smooth, diffusely full, and tapers down in thickness around the periphery. It projects 1-4 cm and the overlying skin is normal.
While I have seen buffalo humps in female and male patients 15 to 70 years old, the typical patient is a female in their late 20’s to early 40’s without any medical issues. Some patients state that it has been present for as long as they can remember and “it runs in the family.” A detailed history often unveils an increase in size over many years. Although most state that diet and exercise do little to decrease the buffalo hump, they report that occasionally it may appear to fluctuate with weight gain or loss, but it seldom disappears. Most patients state that they feel self-conscious about their appearance. Women avoid wearing their hair up. Males and females report avoiding form-fitting shirts and clothing that expose the neck and back. Professional massage therapy is not entertained because they are embarrassed. Furthermore, Intimacy may be dampened.
Physical complaints, though not common, can persist in some patients. Dull aching pain at rest may exist. They may experience discomfort while sleeping or reclining at the dentist or hair salon. They may complain of minor limitations in neck extension, minimal limitations with neck rotation, and a feeling that their neck is “being pushed” or forced in a forward position.
Physical exam demonstrates a circular midline smooth mound of soft tissue with normal overlying skin. It is inferior to the nape of the neck, superior to the middle third of the back, and interscapular. It feels rubbery, gradually blends with the surrounding tissue, and moves similar to normal tissue. The examiner’s fingers cannot get underneath the mound. Superficial and deep palpation does not elicit any significant pain response. Due to mass effect, neck mobility may be limited with full extension and less so with rotation.
A thorough history and physical exam should be more than adequate to proceed with surgical intervention. If the diagnosis is unclear then it is prudent to consider a diagnostic ultrasound 2. A surgeon savvy with “awake” local anesthesia techniques will find it manageable with no more than minimal sedation* as defined by the American Society of Anesthesiologists. Otherwise, general anesthesia is utilized and the airway is thoroughly secured. The patient’s neck is flexed in a prone position to provide excellent exposure. Numbing solution is injected in a true, tumescent fashion through a single inferior midline incision. Power-assisted suction lipectomy is commenced utilizing a 3 mm blunt-tipped cannula. The thick overlying skin tolerates extensive soft tissue thinning so the subcutaneous space is exhausted of as much fat as possible. Failure to do this will result in partial treatment. The periphery is blended with the surrounding tissue using a 2.5 mm diameter cannula with smaller aspiration holes. Patients seek an aesthetically pleasing normal concavity, therefore the endpoint is a uniformly depressed surgical site. The incision is left open to promote drainage. The patient is padded and placed in a custom dorsocervical compression garment.
Not surprisingly, complete treatment of the buffalo hump has a high patient satisfaction. They express gratitude within the early post-operative period. By three months, patients frequently report that the results are “life changing.” In my experience, the scar is insignificant, and I do not recall a time that a patient has complained. A seroma is the most common early complication, albeit less than 1%; it is easily treated with needle aspiration and compression. Discomfort and mobility issues resolve in patients with and without preoperative physical complaints. Changing a curved or bent appearing neck into a more straight neck appears to be an added bonus of the treatment. Partial treatment of the buffalo hump is less satisfying and a portion of these patients may seek additional treatment. Fortunately, the recurrence of the buffalo hump with idiopathic causes is not seen and only appears to be an issue with humps secondary to stimuli such as medications or disease states.
An aesthetically pleasing human body has subcutaneous fat found over muscle and very little subcutaneous fat over tendons. A sculpted midline lower neck and upper back is attractive and portrays good health. I have never seen a Greek bust or statue with a dorsocervical fat pad. With increasing knowledge and self awareness, the idiopathic buffalo hump is a common cosmetic concern. It is often the primary reason for the consultation and usually accompanies emotional distress. Most patients who seek treatment are without significant medical problems and are normal to overweight. The surgeon should suspect other pathologies if the patient states that the mass has appeared suddenly over the last 6-12 months and is not midline on physical exam. Surgical treatment of the buffalo hump is straight forward for both the patient and the surgeon. Performing the procedure awake with excellent local anesthesia technique simplifies the whole preoperative and operative experience. Removing even the smallest hump is highly rewarding. Partial treatment may require additional revision liposuction. It is noted that revision is considerably more difficult due to the combination of scar tissue and the naturally fibrous environment. Overall, successful treatment of the buffalo hump builds confidence in the doctor-patient relationship, and frequently leads to other cosmetic discussions and interventions.
*Defined by the American Society of Anesthesiologists as anxiolysis with normal response to verbal stimulation, an unaffected airway, unaffected spontaneous ventilation, and unaffected cardiovascular function.
- Berman, Ruth. (2009). ‘Bison or Buffalo?’ American Bison. Lerner Publications Company. Page 9.
- Lo, W.K., Yuen, M.K.E. (2017, June). The Buffalo Hump: Sonographic differentiation of a prominent dorsocervical fat pad from lipoma. Poster presented at the European Society of Musculoskeletal Radiology, Bari, Italy.