I'm 23. I have Dermatillomania, and picking has made my lower eye skin sink. I look old and tired. What are my options? (Photo)

Many individual who suffer from this condition are not able to face the truth.  You are not a candidate for fillers or surgery in my opinion because the risk of self-harming the healing tissue is simply too great.  The risk of this might possible be managed if you are under psychological care for excoriation disorder.  I do not think that online CBT treatments are adequate for this.  As you live in San Francisco, I recommend you consider seeing John Koo, M.D. at the Department of Dermatology at the University of California, San Francisco.  He is a practicing dermatologist who is also a board certified psychiatrist.  As far as I know, there is only one other physician so trained in the United States and she practices in New York City.  Get the appropriate care you need for the dermatillomania before considering any cosmetic surgery.  You will be doing yourself a big favor.

You appear to be a good candidate for lower eyelid tear trough filler injection, rather than surgery. This is done in the office under topical anesthesia. See an oculoplastic specialist.

You are an ideal candidate for transconjuctival access to remove your prominent fat bags; find a surgeon expert in this delicate technique and you'll be very happy.No fillers at all!