Background <p>Preservation rhinoplasty has recently shown a dramatic rise in acceptance within the field of rhinoplasty among facial plastic surgeons. The study aimed to compare aesthetic and functional nasal outcomes between let down preservation rhinoplasty and conventional rhinoplasty in patients with dorsal hump more than 4&#xa0;mm.</p> Patient and methods <p>A prospective randomized clinical study was conducted in the Otorhinolaryngology Department between December 2021 and December 2023.</p> <p>Patients were divided randomly into 2 groups named A and B. Patients in group A underwent open let-down rhinoplasty, while those in group B underwent open conventional rhinoplasty. Aesthetic and functional nasal outcomes of the two groups were compared both pre- and postoperatively using the SCHNOS questionnaire.</p> Results <p>No statistically significant difference was reported between groups A and B in the preoperative SCHNOS questionnaire results. Regarding postoperative results, a statistically significant difference between the two groups as regards postoperative congested nose (<i>P</i> = 0.002), where more cases among group B had postoperative congested nose than group A. Cases among group A and group B showed significant postoperative improvement as regards all items of the questionnaire.</p> Conclusion <p>Both let down preservation rhinoplasty and conventional rhinoplasty techniques were associated with promising aesthetic and functional nasal outcomes. However, let down preservation rhinoplasty results show significantly less postoperative congested nose than conventional rhinoplasty.</p>