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Background: Skin tattoos are a common decoration, but profound scientific study whether the presence of a skin tattoo alters the acoustic response from superficial tissue, and therefore from underlying tissue, was previously lacking. Any image aberrations caused by tattoo presence may have been thought negligible, yet empirically found artifacts in brightness-mode images of tattooed skin suggest otherwise. This study investigated the nature of these artifacts theoretically and experimentally in extremely simplified cases of perfectly flat and homogenous layered media and in tattooed pork. Methods: Theory was derived for computing the acoustic response from horizontally and vertically layered media containing a thin inked layer. Experiments were performed in vitro. Artificial and pork skin were tattooed, attached to phantom material, and sonicated with a 13–6-MHz probe. The speed of sound of these materials was determined, and the perceived refraction angles was measured. Results: The measured speeds of sound of tattooed materials were higher than those of their uninked counterparts. The presence of tattoo ink was found to have increased the linear acoustic attenuation by 1 dB/cm. This value is negligible for typical tattoos of only few millimeters. The perceived critical refraction angles of adjacent materials could be detected, and their corresponding speeds of sound were quantified. These coincided with values derived from theory. Conclusion: The ratio of speeds of sound of adjacent materials was shown to create distinct highlights in brightness-mode images. The artifacts observed in in vitro and in vivo brightness-mode scans were explained from near-vertical transitions between areas of different sound speed. This is the first study correlating so-called critical refraction highlighting with speed-of-sound information. In addition, it was found that phantom material is a room-temperature acoustic alternative for experiments on live human skin. In summary, the presence of superficial tattoos has a small but quantifiable effect on the acoustic response from deeper tissues.