<i>Background</i> <p>Buffalo hump is not an exclusive condition in patients with human immunodeficiency virus (HIV), as many cases present without a clear etiology. Therefore, we classified buffalo humps according to their clinical appearance and magnetic resonance imaging (MRI) data, establishing categories based on clinical classification to inform clinical management.</p> <i>Methods</i> <p>Patients who underwent surgical treatment for buffalo hump between March 2018 and March 2025 were analyzed in this retrospective study. The clinical appearance, MRI, pathology, and postoperative outcomes were evaluated. Two senior plastic surgeons independently assigned classification and grading based on predefined appearance and MRI images.</p> <i>Results</i> <p>This study included 383 patients, of whom only one was HIV-positive. Buffalo hump was classified into four types—type I (dorsocervical fat pad, 77.57%), type II (dorsocervical fat accumulation, 11.23%), type III (nuchodorsal lipoma, 10.18%), and type IV (mixed type, 1.04%). None of the patients who underwent surgery experienced recurrence. The postoperative complications included cutaneous numbness (14.36%), seroma (6.27%), hypertrophic scar (2.09%), and hematoma (0.78%).</p> <i>Conclusion</i> <p>This study proposes a classification for buffalo hump based on clinical appearance and MRI. The classification offers clear surgical recommendations for the treatment of buffalo hump. Buffalo hump is not a clinical manifestation exclusive to HIV-positive patients.</p> Level of Evidence IV <p>This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors <a href="http://www.springer.com/00266">www.springer.com/00266</a>.</p>