199R. Jankowski, The Evo-Devo Origin of the Nose, Anterior Skull Base and Midface, DOI 10.1007/978-2-8178-0422-4_20, © Springer-Verlag France 2013

The previous chapter shows that it may be possible to develop hypotheses on patho-genesis, which are built on knowledge of evolution and development. In comparison to the current (classical) hypotheses on pathogenesis of diseases like juvenile nasopharyngeal angio fi broma or nasal polyposis or others, or in comparison to the current general frame of chronic rhinosinusitis proposed to approach the diseases of the nose, it seems that evolutionary hypotheses present some interest. Pathogenesis frequently leads to treatments, and evolutionary medicine could be de fi ned by all medical diagnosis or treatments based on evolutionary- and developmental-derived knowledge.

20.1 Septorhinoplasty Conceptualized Within a Framework of Separately Evolved Units

I just would like to take this opportunity to give one personal example of how evolu-tion and development knowledge about the formation of the nose has modi fi ed my surgical approach in rhinoplasty for the correction of primary deformities of the nasal pyramid, that is, deformities which appear with the progressive growth of the nose in the fi rst quarter of postnatal life, either under genetic drive or in reaction to successive minor traumas disturbing the development of the nose (even in absence of any fracture) ( Boulanger et al. submitted ) . To understand the pathogenesis of these growth deformities, I considered the nose with its three different origins. The carti-laginous nasal pyramid (alar + septotriangular cartilages) is the super fi cial part of the olfactory nose, and I have observed during surgery that it stays connected to the deep olfactory nose (the olfactory mucosa embedded in the ethmoid capsule) by a layer of fi brous tissue which connects the perichondrium of the cartilages to the mucosa of the olfactory cleft (Fig. 11.2c, d ) and which probably represents a remnant of the invagination process of the olfactory placode into the frontonasal process. The osseous nasal pyramid (ascending processes of the maxillary bones + nasal bones)

Chapter 20 Evolutionary and Developmental (Evo-Devo) Medicine

200 20 Evolutionary and Developmental (Evo-Devo) Medicine

corresponds to the junction between the frontonasal and maxillary processes around the invagination ori fi ce of the olfactory nose (i.e., the pyriform aperture). It seems that the formation of the respiratory nose between olfactory nose and mouth is in most of the cases the disturbing factor of the growing process of the nasal pyramid, with major growing con fl icts being located at the level of the nasal septum, where the opposite growing directions of the septal cartilage, perpendicular plate, and the vomer bones meet.

Thus, the key point for the correction of the deformities resulting from this con fl icting growth pattern is to release the con fl icts (1) at the level of the nasal sep-tum by freeing the septal cartilage from its bony frame and removing septal bone to give space for re-expansion to the septal cartilage and (2) at the level of the pyriform aperture by detaching the septolateral cartilage under the bony nose, taking care to preserve the membrane which connect it to the mucosa of the olfactory cleft. In this procedure, the cartilaginous nose is actually disarticulated from the bony nose. It becomes then easy (1) to correct the deformations of the bony pyramid (removal of a bony hump, realignment of the ascending processes, narrowing of the frontal base of the bony pyramid, etc.) and (2) to remodel and adjust the septolateral cartilage under the reshaped bony pyramid, before (3) correcting, if necessary, the alar carti-lages and the tip and base of the nasal pyramid.

This technique of septorhinoplasty by disarticulation of the cartilaginous and bony noses is based on the evolutionary and developmental understanding of the nose formation and is different in its approach from the other current techniques, like the classical Joseph hump resection that removes in one piece the bony-cartilaginous dorsum but usually is associated to reconstruction techniques of the septolateral unit or the classical Cottle septorhinoplasty with hump push-down that preserves the junction between cartilaginous and bony dorsum but sometimes also the elastic forces for a recurrence of the hump.

20.2 Pelvis Surgery Conceptualized According to Evo-Devo Knowledge

There are other examples showing that evo-devo knowledge may in fl uence surgical techniques. Embryology provides a key to understand the complex topography of the human pelvic girdle and leads to a rational conceptualization of its surgical anatomy.

In the surgical treatment of rectal cancer, a signi fi cant improvement with respect to postoperative sequelae, locoregional recurrences, and survival was achieved by the introduction of the total mesorectal excision (TME), a high-resolution sharp dis-section of the rectum and its integrated mesentery based on developmentally de fi ned topographic anatomy (Heald 1982 ) .

More recently, (Höckel et al. 2003 ) have developed the total mesometrial resec-tion (TMMR) as a surgical approach to carcinoma of the uterine cervix on the basis of developmentally de fi ned surgical anatomy. With reference to the uterine cervix,

20120.3 There May Be Many Other Examples in Medicine

the proximal vagina, corpus, bilateral mesometrium, and dense subperitoneal con-nective tissue of the rectouterine pouch all constitute a single developmental unit. The mesometrium originates from the migration of the paramesonephric ducts dur-ing the embryologic development from the dorsolateral mesonephros toward the center of the pelvis where they fuse to form the uterus and the proximal vagina (O’Rahilly and Muller 2001 ) . Total mesometrial resection, the excision of the uterus and proximal vagina together with its integrated mesentery as single unit, supple-mented by extended pelvic/periaortic lymph node dissection, differs from the tradi-tional Wertheim-Meigs operation. During conventional radical hysterectomy, the mesometrium is not completely exposed but is clamped together with the dense subperitoneal connective tissue and sometimes even with parts of the mesorectum, bladder mesentery, and obturator lymph node tissue within the perivisceral parietal pelvic adipose tissue (together referred to as parametrium/paracolpium) by use of traumatic instruments (e.g., Wertheim clamps) before transection. As a consequence remnants of the mesometrium which may contain tumor cells may be left behind within or close to secondary healing wounds. The interference of these residual occult tumor cells with the microenvironment of the parametrial wounds causes the majority of pelvic recurrences.

TME has been presented as a new concept in surgical oncology which is charac-terized by the removal of the diseased organ together with its integral mesentery as a developmentally de fi ned (ontogenetic) entity. Surgery is performed sharply with high resolution and minimal trauma within the cancer fi eld, leading to less local recurrences, less need for adjuvant (chemo) radiotherapy, less postoperative seque-lae, and better quality of life.

20.3 There May Be Many Other Examples in Medicine

There may be many other examples in medicine which illustrate the relationship between evo-devo knowledge, pathogenesis, and treatment. One of them is the well-known description by Cushing ( 1912 ) of the endonasal route for removing pituitary tumors, which is the evolutionary and developmental route followed by the anterior pituitary gland to sit in its anatomical location. This surgery, which was initially performed with the unaided eyes and required extraordinary skill, has recently been considerably improved by the use of endoscopes (Jankowski et al. 1992 ).

Summary The way one understands a disease leads to the way he treats the patient. Pathogenesis frequently leads to treatments, and evolutionary medicine could be de fi ned by all medical aspects founded on evolutionary- and developmental- derived knowledge. One personal example is how the evolutionary and devel-opmental concept of the nose formation has modi fi ed my surgical approach to

202 20 Evolutionary and Developmental (Evo-Devo) Medicine

References

Boulanger N, Baumann C et al (submitted) Septorhinoplasty by disarticulation: Early assessment of a new technique for morphological correction of crooked noses. Rhinology

Cushing H (ed) (1912) The pituitary body and its disorders. J.B. Lippincott Co, Philadelphia Heald RJ, Husband EM et al (1982) The mesorectum in rectal cancer surgery: The clue to pelvic

recurrence? Br J Surg 69:613–616 Höckel M, Horn LC et al (2003) Total mesometrial resection: High resolution nerve-sparing radi-

cal hysterectomy based on developmnetally defi ned surgical anatomy. Int J Gynecol Cancer 13:791–803

Jankowski R, Auque J et al (1992) Endoscopic pituitary tumor surgery. Laryngoscope 102(2):198–202

O’Rahilly R, Muller F (2001) Human embryology and teratology. 3rd edn. New York: John Wiley & Sons

septoplasty and rhinoplasty for the correction of primary deformities of the nasal septum or pyramid. Septorhinoplasty by disarticulation between the car-tilaginous and bony noses proposes an approach different from that of the other current techniques. There are other examples showing that evolutionary concepts may in fl uence surgical techniques. The study of embryologic and fetal development also provides a key to understanding the complex topogra-phy of the human pelvic girdle and, as a consequence, offers a new conceptu-alization in surgical oncology. Cushing ( 1912 ) was probably the fi rst to take advantage of the endonasal route to remove pituitary tumors, by following the evolutionary and developmental route that lead to the formation of the ante-rior pituitary gland.