How to remove a buffalo hump (dorsocervical fat pad) after exogenous Cushing's syndrome?

Management of Buffalo Hump After Exogenous Cushing's Syndrome

The most effective approach for removing a buffalo hump (dorsocervical fat pad) after exogenous Cushing's syndrome is surgical intervention through liposuction or direct excision when the fat deposit persists despite normalization of cortisol levels.

Understanding Buffalo Hump in Exogenous Cushing's Syndrome

Buffalo hump (dorsocervical fat pad) is a characteristic physical manifestation of Cushing's syndrome, reported in up to 50% of patients with steroid-induced Cushing's syndrome 1. This fat accumulation in the dorsocervical region occurs due to the redistribution of adipose tissue caused by excessive glucocorticoid exposure.

Initial Management Approach

1. Confirm Resolution of Hypercortisolism

   • Ensure that exogenous steroid use has been discontinued or minimized to the lowest effective dose
   • Verify normalization of cortisol levels if still on steroid therapy

2. Wait for Spontaneous Improvement

   • Many Cushingoid features, including buffalo hump, may gradually improve after normalization of cortisol levels
   • Allow 6-12 months for potential spontaneous resolution before considering invasive interventions

Interventional Options for Persistent Buffalo Hump

When the buffalo hump persists despite normalization of cortisol levels, the following interventions may be considered:

Surgical Options (First-line for persistent cases)

1. Liposuction

   • Most effective for well-localized adipose tissue deposits
   • Less invasive than open surgical excision
   • Allows for targeted removal of the dorsocervical fat pad
   • Can be performed under local anesthesia with sedation

2. Direct Surgical Excision

   • Appropriate for larger or more fibrous buffalo humps
   • May be necessary when liposuction alone is insufficient
   • Allows for removal of both fat and fibrous tissue

Important Surgical Considerations

• Surgical planning should account for the potential skin redundancy after fat removal
• The procedure should be performed by a surgeon experienced in treating this specific condition
• Post-surgical compression garments may be recommended to optimize cosmetic outcomes

Monitoring and Follow-up

• Regular follow-up to assess for recurrence, especially if exogenous steroid use continues
• Monitor for potential surgical complications including hematoma, seroma, or infection
• Assess patient satisfaction with cosmetic outcome

Potential Pitfalls and Caveats

• Buffalo hump may recur if exogenous steroid therapy is resumed or continued at high doses
• Surgical intervention addresses only the cosmetic aspect and not the underlying cause
• Patients should have realistic expectations about the cosmetic outcome
• Surgical intervention should be delayed until cortisol levels have normalized to reduce surgical risks
• Distinguish true buffalo hump from other causes of dorsocervical fat accumulation (e.g., HIV-associated lipodystrophy, which can present similarly) 2

Special Considerations

• In cases where the buffalo hump is part of a broader metabolic disorder, addressing the underlying condition is essential
• For patients requiring ongoing steroid therapy, using the lowest effective dose and considering steroid-sparing agents may help prevent recurrence

By following this algorithmic approach, the dorsocervical fat pad can be effectively managed in patients with a history of exogenous Cushing's syndrome, improving both physical appearance and potentially quality of life.