Technically yes, it is all repainted but I definitely use photo reference, but not for the elements you might think. It's strange but I hollow out the image almost list a coloring book and once the basic contours and proportional relationships are all locked in, I start layering new elements of invention. But yeah, ultimately there is an amalgam of drawn/painted pixels. It almost feels like sculpting.
Wish I could find a better analogy. But it is about as painstakingly slow working in digital as oil used to be. This particular work took a lot of hour/days. Had to really slow down. I also work on the various elements separately, almost as smaller studies. Figures go the same way. I have sketchbooks filled with just parts.