Background Sarcomas guidelines suggest soft tissue lumps ≥5cm, enlarging, painful or deep are considered malignant unless proven otherwise, should undergo a magnetic resonance imaging (MRI) scan and referred to a specialist centre. Secondary hospitals receive multiple referrers from primary care for workup of subcutaneous, soft tissue lesions ≥5cm with no other high-risk features. Strict adherence to recommendations can lead to overutilisation of limited resources. Methods We performed a single centre, retrospective cohort study at St John of God Midland Hospital in Western Australia, Perth on 552 patients investigated for subcutaneous, soft tissue lesions from 24 November 2015 to 30 September 2024. Results 83.5% (461/552) of lesions were excised locally. 31.9% (147/461) had ≥1 high-risk clinical feature but none were atypical or malignant. Histological lipomas were the most common at 83.51% (385/461) followed by angiolipomas at 9.1% (42/461). 0.7% (3/461) of lesions showed atypia or malignancy and were all <5cm. Pre-operative ultrasound was most commonly utilised at 56.2% (259/461) followed by MRI at 19.1% (88/461), with ≥ 94% sensitivity in identifying benign lipomas. 16.5% (91/552) of lesions had radiological high-risk features. 54.9% (50/91) were managed at our state sarcoma unit. 84% (42/50) underwent marginal excision with 1 histological sarcoma which had typical clinical and imaging features of malignancy. Conclusion 75% (3/4) of lesions with atypia/malignancy were <5cm. This emphasises the importance of offering excisions to all soft tissue lesions with interval change in size. We believe clinical assessment and USS is adequate to identify high-risk lesions, and size alone should not be the sole indicator for escalation.