The dorsocervical fat pad, or more colloquially known as a buffalo hump, is a localised fat deposition on the upper back typically associated with conditions like Cushing's syndrome or can be seen as a side effect of antiretroviral drugs). This condition can present significant clinical and aesthetic challenges, and be a huge physical and psychological discomfort to patients. This review will discuss the two possible surgical intervention: excision vs liposuction. Direct excision is a more traditional approach that can be most effective in those with particularly dense, fibrous fat deposits that may be challenging to address with liposuction. The advantages of direct excision include the complete removal of the fat pad and potential for immediate, visible results. Liposuction on the other hand, is a much less invasive surgical technique and is preferred for those with more favourable fat pockets and can achieve a smaller scar, however this comes a the cost as the potential need for repeat procedures if all the desired fat isn't removed in the first session. Ultimately this can be a challenging condition to treat, and he choice between direct excision and liposuction for buffalo hump management depends on individual patient factors.