Objectives: To find out whether there is a difference in the incidence of injection pain and other complications using pre-cooling versus the buffered equivalent in upper blepharoplasty. Methods: A prospective, randomized study in patients scheduled for primary upper blepharoplasty was performed. Each subject was his/her own control by performing pre-cooling for 2 min before plain lidocaine injection in one eyelid, while the buffered solution injection was used in the other eyelid. Data were collected regarding injection pain, postoperative pain, bleeding, bruising, swelling and scar appearance. Results: Sixty patients participated in this study. Injection pain, checked immediately, revealed a mean operative pain rating of 2.20 +/- 0.32 in the eye with pre-cooling versus 2.30 +/- 0.35 in the buffered lidocaine (p = 0.074). A statistical difference was observed in postoperative pain after 2-4 h, with the pre-cooling group having a score of 4.00 +/- 0.14 versus 4.40 +/- 0.30 in the buffered lidocaine group (p = 0.021). The postoperative pain after 24 h was 2.00 +/- 0.56 in the pre-cooling group versus 2.30 +/- 0.23 in the buffered lidocaine group (p = 0.006). There were no statistical differences between the buffered and unbuffered lidocaine eyes after 2 days or 1 week in regard to postoperative pain, bleeding, swelling, bruising and scar appearance. Conclusions: Pre-cooling could induce similar injection pain relief to that of buffered lidocaine while maintaining longer postoperative anesthetic results than buffered lidocaine.