Seeing the final image and understanding the process seems to be confusing for a lot of people. I've been asked if I paint the actual person before taking the photo, or if I pose a skeleton (!!), or if I create it in Photoshop. All legitimate questions, but all off base.
What I do is take a regular portrait using film, print it on fiber base paper in a traditional, wet darkroom, then use oil paints (acrylic on the earlier versions) to paint in some of the background and add the skeleton. After the paint dries, I scan the image, use Photoshop to take out any light reflections on the oil paint that happen during scanning, and make reproduction prints. Scanning the image and turning it into a black and white file helps even out the black and white paint to blend with the original tones of the black and white photograph.